LODI CREEK POST ACUTE
For profit - Limited Liability company
86 Beds
LINKS HEALTHCARE GROUP
Data: November 2025
Trust Grade
70/100
#389 of 1155 in CA
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Lodi Creek Post Acute has a Trust Grade of B, which indicates it is a good choice among nursing homes, offering solid care. It ranks #389 out of 1,155 facilities in California, placing it in the top half, and #7 out of 24 in San Joaquin County, meaning only six local options are better. The facility is improving, with issues decreasing from 20 in 2024 to just 2 in 2025. Staffing is average with a turnover rate of 45%, slightly higher than the state average, but there are no fines on record, which is a positive sign. However, there are concerns regarding medication management; for instance, some emergency medication kits were not logged properly, and expired medications were found in storage, which could jeopardize resident safety. Additionally, the kitchen had issues with sanitizing solutions, raising the risk of foodborne illnesses.
- Trust Score
- B
- In California
- #389/1155
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 45% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 33%
No red flags
20 → 2 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 20 issues
2025: 2 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (45%)
3 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 45%
Near California avg (46%)
Typical for the industry
Chain: LINKS HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 43 deficiencies on record
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to implement their infection control policy and procedure by failing to ensure that two of six sampled residents (Resident 1 and Resident 4) ...
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Based on interview, and record review, the facility failed to implement their infection control policy and procedure by failing to ensure that two of six sampled residents (Resident 1 and Resident 4) were tested for COVID-19 after being exposed to a COVID-19 (a contagious disease) positive resident.This deficient practice had the potential to place residents, staff members, and visitors at risk for spreading infection. There was also the potential to cause further delay in the treatment for Resident 1 and Resident 4.Findings:a. Resident 4's admission RECORD indicated Resident 4 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease (group of lung diseases that cause long-term breathing problems). A review of Resident 4's medical record titled, SBAR & INITIAL COC/ALERT CHARTING & SKILLED DOCUMENTATION, dated 7/14/25, indicated, .Pt [Patient] tested for COVID19 via rapid nasal swab with positive result.A review of Resident 3's medical record titled, SBAR [Situation Background Assessment Recommendation- communication form] & [and] INITIAL COC [Change of Condition]/ALERT CHARTING & SKILLED DOCUMENTATION, dated 7/9/25, indicated, .Patient [Resident] tested positive for COVID 19 on rapid testing.During an interview on 7/15/25, at 2:38 PM, with License Nurse (LN) 1, LN 1 stated when a resident tested positive for COVID-19, the facility staff should have tested the roommate of the positive resident.During an interview on 7/15/25, at 2:53 PM, with Resident 3, Resident 3 stated she tested positive for COVID-19 on 7/9/25. Resident 3 further stated she was not moved to a different room when she tested positive for COVID-19, and her roommate (Resident 4) also remained in the same room.During a concurrent interview and record review on 7/15/25, at 3:49 PM, with the Infection Preventionist (IP), Resident 4's medical record was reviewed. The IP stated as a general practice, the facility staff swabbed the residents who had symptoms of COVID-19 and the residents who had been exposed to the virus. The IP further stated that exposed residents would have been tested on day 1, day 3, and day 5. The IP explained that the staff should have immediately tested the roommate of any COVID -19 positive resident. The IP confirmed the facility did not have documentation that Resident 4 (the roommate of Resident 3), was tested for COVID-19 on 7/10/25 and 7/12/25. The IP further confirmed there was no documentation for Resident 4 that testing was completed. b. Resident 1's admission RECORD indicated Resident 1 was admitted to the facility in 2019 with diagnoses including multiple sclerosis (a chronic neurological disorder affecting the brain and spinal cord).A review of Resident 1's Care Plan, initiated on 7/3/25, under the Focus section, indicated, .PERSON UNDER MONITORING: ASYMPTOMATIC [no symptoms] resident who is at risk for Respiratory Illness due to possible exposure to Covid-19. A review of Resident 2's medical record titled, SBAR & INITIAL COC/ALERT CHARTING & SKILLED DOCUMENTATION, dated 7/3/25, indicated, .Noted resident with a hoarse voice, c/o [complaint of] congestion and sore throat.Resident then swabbed via rapid COVID test, positive result.During a concurrent interview and record review on 7/16/25, at 11:50 AM, with the IP, Resident 1's medical record was reviewed. The IP stated as a facility practice, the facility waited for 24 hours before they tested asymptomatic residents that had a positive COVID-19 roommate, and if the resident was symptomatic, the staff immediately performed a COVID -19 test. The IP further stated it was important to test the roommate because there was a potential to spread the infection. The IP confirmed that Resident 1 did not have documentation of the COVID-19 test completed when her roommate (Resident 2) tested positive on 7/3/25. During a concurrent interview and record review on 7/16/25, at 1:53 PM, with the Director of Nursing (DON), Resident 4 and Resident 1's medical records were reviewed. The DON stated if the result of the first COVID-19 test was negative, the nursing staff should have continued with the testing for the third and fifth day of exposure. The DON further stated that when a resident tested positive for COVID-19, the nursing staff should have tested the roommate for COVID-19 within 24 hours. The DON stated she expected the nursing staff to document when a resident was tested for COVID-19 because if they did not document, it meant it was not done. The DON confirmed that Resident 4 had no documentation that she was tested for COVID-19 within 24 hours of exposure from her roommate Resident 3. The DON further confirmed that Resident 1 had no documentation that she was tested for COVID-19 within 24 hours of exposure from her roommate (Resident 2) or on the succeeding days. A review of undated facility document titled, Coronavirus Disease (COVID-19) -Infection Prevention and Control Measures, indicated, .The infection prevention and control measures that are implemented to address the SARS-CoV-2 pandemic are incorporated into the facility infection prevention and control plan. These measures include.performing testing as recommended by current guidelines. According to the Centers for Disease Control and Prevention (CDC) publication titled, Infection Control Guidance: SARS-CoV-2, dated June 24, 2024, indicated, .Perform SARS-CoV-2 Viral Testing.Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5.
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to provide the proper notice for discharge for Resident 1 when:
1. Resident 1 was not given a 30-day advance written notice of the impending ...
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Based on interview, and record review, the facility failed to provide the proper notice for discharge for Resident 1 when:
1. Resident 1 was not given a 30-day advance written notice of the impending transfer or discharge from the facility,
2. The facility did not notify or send Resident 1's Notice of Transfer or Discharge form to the Ombudsman's office (a government appointed person who actively supports the rights of the residents) on the same day that Resident 1 was served the notice; and,
3. The location listed on Resident 1's Notice of Transfer or Discharge (a document given by the facility to the resident indicating an upcoming transfer or discharge from the current facility to another location) did not match the location listed on Resident 1's discharge order location.
These failures could have resulted in Resident 1 not having the opportunity to have had an advocate to inform him of his right to appeal, and Resident 1 could have had an inappropriate transfer or discharge.
Findings:
1. A review of Resident 1's medical record titled, admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses that included acute respiratory failure (the inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues), influenza (a viral respiratory illness that causes symptoms like fever, chills, cough, and body aches) and pneumonia (an infection that inflames the air sacs in one or both lungs).
A review of Resident 1's medical record titled, Notice of Transfer/Discharge, indicated a notification date of 3/4/25 and was signed by Resident 1 on 3/8/25.
During an interview on 5/8/25, at 9:43 a.m., with Resident 1, Resident 1 stated on 3/8/25 he was verbally told by facility staff that he was getting discharged because he had recovered enough. Resident 1 further stated he was given the discharge paperwork on the same day the facility was trying to discharge him on 3/8/25. Resident 1 stated there was no information or paperwork given by the facility to him about discharging prior to 3/8/25.
During a concurrent joint interview and record review on 5/8/25, at 12:42 p.m., with the Social Services Director (SSD) and the Case Manager (CM), the CM stated the facility did not issue the discharge notice for residents with Medi-Cal coverage because it was already discussed through the care conference meetings with the residents. The CM further stated Resident 1 received the Notice of Transfer or Discharge notice on 3/8/25 as part of the discharge paperwork. The CM stated the Notice of Transfer or Discharge would include the reason for discharge and resources on their right to file an appeal. Both the SSD and the CM confirmed Resident 1's Notice of Transfer or Discharge had a notification date of 3/4/25 but was signed by Resident 1 on 3/8/25.
2. During an interview on 5/8/25, at 9:43 a.m., with Resident 1, Resident 1 stated he called the Ombudsman's office on 3/8/25 when the facility was trying to discharge him and was told by the Ombudsman their office did not receive a copy of Resident 1's Notice of Transfer or Discharge.
During an interview on 5/8/25, at 11:36 a.m., with the Ombudsman (OMB), the OMB stated Resident 1 called the Ombudsman's office on the after-hours line late in the afternoon on 3/8/25 to report the facility was discharging him. The OMB confirmed the Ombudsman's office did not receive Resident 1's Notice of Discharge or Transfer from the facility. The OMB stated their office usually received a 30-day notice prior to discharge from the facility so that the residents would be notified of their right to appeal and to have enough time to make arrangements for discharge.
During a concurrent joint interview and record review on 5/8/25, at 12:42 p.m., with the SSD and the CM, the CM stated the Notice of Transfer or Discharge notice would be sent over to the Ombudsman's office on the discharge date via fax. The CM further stated Resident 1's Notice of Transfer or Discharge was not sent to the Ombudsman's office because the discharge did not happen. The CM stated the expectation was to send the Notice of Transfer or Discharge to the Ombudsman's office on the day of Resident 1's discharge.
During an interview on 5/8/25, at 1:38 p.m., with the ADON, the ADON stated the Notice of Transfer or Discharge was usually sent out to the Ombudsman's office via fax on the day of resident's discharge. The ADON stated that the importance of sending Resident 1's Notice of Transfer or Discharge to the Ombudsman's office was for the Ombudsman to be aware that Resident 1 was discharging to the community and if there were follow-ups needed to be done on their end.
3. A review of Resident 1's medical record titled, Notice of Transfer/Discharge, indicated a notification date of 3/4/25 and was signed by Resident 1 on 3/8/25, with a discharge Transfer or Discharge location to [Name of Homeless Shelter 1].
A review of Resident 1's doctor's order, dated 2/27/25, indicated .MAY DISCHARGE TO [Name of Homeless Shelter 2] 03/08/25 WITH HOME HEALTH, RN, PT, OT, STANDARD WHEELCHAIR AND 7 DAYS MEDICATION SUPPLY .
During an interview on 5/8/25, at 9:43 a.m., with Resident 1, Resident 1 stated that he was homeless and previously lived at Homeless Shelter 1 prior to being hospitalized . Resident 1 stated the facility planned the discharge on the discharge paperwork on 3/8/25 to be discharged to Homeless Shelter 2.
During a concurrent interview and record review on 5/8/25, at 10:39 a.m., with the Licensed Nurse (LN), LN reviewed Resident 1's chart and confirmed Resident 1's discharge location was at Homeless Shelter 2.
During an interview on 5/8/25, at 11:36 a.m., with the Ombudsman (OMB), the OMB stated she was not familiar with Homeless Shelter 2 and was told by the facility's SSD that Resident 1 was being discharged to a homeless shelter where he was originally from. The OMB further stated residents should not be discharged to a homeless shelter because the beds were not guaranteed.
During a concurrent joint interview and record review on 5/8/25, at 12:42 p.m., with the SSD and the CM, Resident 1's Notice of Transfer or Discharge and discharge order were reviewed. The SSD and CM both confirmed that the discharge order dated 2/27/25 for Homeless Shelter 2 did not match the location listed on Resident 1's Notice of Transfer or Discharge. The SSD and CM both stated the discharge order location and Notice of Transfer or Discharge location should have matched. The SSD and the CM explained they were both responsible in ensuring the discharge orders and Notice of Transfer or Discharge matched.
During a concurrent interview and record review on 5/8/25, at 1:38 p.m., with the ADON, the ADON reviewed Resident 1's discharge order dated 2/27/25 and Resident 1's Notice of Transfer or Discharge form. The ADON confirmed the discharge locations did not match and stated staff were expected to ensure that both locations listed matched.
During an interview on 5/8/25, at 3:02 p.m., with the Administrator (ADM), the ADM stated it was his expectation for the facility staff to follow the facility's policy when providing residents with the Notice of Transfer or Discharge. The ADM stated that it was important to provide the Notice of Discharge or Transfer to Resident 1 to provide information on Resident 1's right on how to appeal the discharge.
A review of the facility's policy titled, Transfer of Discharge, Facility-Initiated, dated 10/22, indicated .Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy .Notice of Transfer or Discharge (Planned) .1. Except as specified below, the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility .Notice of Transfer or Discharge (Emergent or Therapeutic Leave) .2. The resident and representative are notified in writing of the following information .The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is being transferred or discharged .3. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative .5. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge .b. The resident's health improves sufficiently to allow a more immediate transfer or discharge .6. Notice of transfer is provided to the resident and representative as soon as possible before the transfer and to the long-term care (LTC) ombudsman when practicable .
A review of an online document published by the California Advocates for Nursing Home Reform (CANHR) titled, TRANSFER AND DISCHARGE RIGHTS, updated 9/4/24, indicated .Federal and California laws provide strong protections against evictions of nursing home residents. Residents have very specific rights that are intended to prevent inappropriate, unnecessary and untimely transfers and discharges .Written Notice .Before transferring or discharging a resident, the facility must provide written notice to the resident and the resident's representative in a language and manner they understand. 42 CFR §483.15(c)(3)(i). The facility must send a copy of the notice to the long-term care ombudsman program. Except when specified below, the notice must be given at least 30 days before the resident is transferred or discharged (see the next section) .Exceptions to 30-Day Notice .As mentioned above, there are a few exceptions to the 30-day notice requirement. Federal regulations permit notice to be made as soon as practicable before transfer or discharge when: the health or safety of individuals in the facility would be endangered; the resident's urgent medical needs require a more immediate transfer; the resident's health has improved sufficiently to allow a more immediate transfer or discharge; or the resident has resided in the facility less than 30 days. 42 CFR §483.15(c)(4) .Even if an exception to the 30-day notice requirement is satisfied, the facility must nevertheless provide written notice in advance of a proposed transfer or discharge and an opportunity to appeal. A nursing home cannot transfer or discharge a resident while an appeal is pending, unless delay would endanger the health or safety of the resident or other individuals in the facility. 42 CFR §483.15(c)(1)(ii) .California law requires nursing homes to give reasonable advance notice in writing in all cases of transfer or discharge, unless there is an emergency. H&S Code §1599.78, 22 CCR §72527(a)(6) .
https://canhr.org/transfer-and-discharge-rights/
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure professional standards of care were met for one of three sampled residents, (Resident 1) when Resident 1 was not repos...
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Based on observation, interview, and record review, the facility failed to ensure professional standards of care were met for one of three sampled residents, (Resident 1) when Resident 1 was not repositioned or assisted with care needs in a timely manner.
This failure put Resident 1 at risk of discomfort and skin breakdown.
Findings:
A review of Resident 1 ' s admission RECORD, indicated, she was admitted to the facility in late 2024 with diagnoses which included dementia (condition characterized by memory disorders, personality changes, and impaired reasoning) and muscle weakness.
A review of Resident 1 ' s clinical care plan indicated, Resident is at risk for pressure injury development and skin breakdown r/t [related to] immobility, incontinence. Turn and reposition q2h [every 2 hours] and PRN [as needed]
During an observation and interview on 10/29/24, at 12:45 PM, with family member (FM) 1, Resident 1 was observed sitting in her wheelchair, FM 1 was sitting in a chair beside Resident 1. FM 1 stated he visited from 9:30 AM until 2:30 PM everyday and Resident 1 was never repositioned or taken to the bathroom during those times. FM 1 further stated the reason Resident 1 had a urinary tract infection (UTI, when germs enter the urinary tract and cause an infection) was because staff never provided incontinence care (support services for people who are unable to control their bladder or bowel movements.)
During an observation and interview on 10/29/24, at 1 PM, the Speech Therapist (ST) was observed feeding Resident 1 her meal. Resident 1 stated she wanted to go to the bathroom. FM 1 stated she needed to go to the bathroom, but no one would help her. The ST stated staff would assist Resident 1, the ST stated she would inform staff of Resident 1 ' s need.
During an observation and interview on 10/29/24, at 1:33 PM, in Resident 1 ' s room, Resident 1 was observed sitting in her wheelchair. FM 1 stated Resident 1 had not yet been assisted to the bathroom.
During an observation and interview on 10/29/24, at 2:48 PM, in Resident 1 ' s room, Resident 1 was observed sitting in her wheelchair. FM 1 stated staff had not repositioned her or provided bathroom assistance since before he arrived in the morning.
During an interview on 10/29/24, at 2:59 PM, CNA 2 stated she had provided care to Resident 1 between 9 AM and 9:30 AM and transferred her to the wheelchair. CNA 2 stated she could not remember when she next provided care, but she thought she and CNA 1 had provided care at approximately 1 PM.
During an observation and interview on 10/29/24, at 4:03 PM, Resident 1 was observed sitting in her wheelchair. CNA 3 stated Resident 1 was last provided care at 1 PM per verbal shift change report. CNA 3 stated she would provide care to Resident 1 after the evening meal (served around 5 PM).
During an interview on 10/30/24, at 11:44 AM, CNA 1 stated she had not assisted in any care provided to Resident 1 on 10/29/24.
During an interview and record review on 10/29/24, at 3:53 PM, the Health Information Manager (HIM) confirmed Resident 1 ' s documentation for 10/29/24 titled, TURNING & REPSOITIONING EVERY 2 HOURS & PRN [AS NEEDED], was blank after 6 AM. The HIM further confirmed the documentation for 10/29/24 titled, BLADDER CONTINENCE, indicated, Resident 1 had two episodes of incontinence documented at 1:18 AM, and there was no documentation after 1:18 AM. The HIM confirmed there was no documentation to indicate incontinence care/turning and repositioning was provided during the am shift.
During an interview on 10/30/24, at 1:58 PM, the DON stated it was her expectation that all residents would be repositioned every 2 hours and their toileting needs would be met at the same time. The DON stated if the care was not provided there was a risk to Resident 1 of skin breakdown and discomfort. The DON further stated if the documentation was incomplete, she could not confirm the care was provided.
A review of a facility policy titled Activities of Daily Living (ADLs) [activities related to personal care], Supporting, revised March 2018, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADL ' s independently including appropriate support and assistance with mobility (transfer and ambulation, including walking) elimination (toileting).
Sept 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to protect one of 6 sampled residents (Resident 1) from physical abuse when Resident 1's arm was grabbed by Resident 2.
This fai...
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Based on observation, interview, and record review, the facility failed to protect one of 6 sampled residents (Resident 1) from physical abuse when Resident 1's arm was grabbed by Resident 2.
This failure resulted in Resident 1 sustaining a scratch to her arm and felt unsafe in her room.
Findings:
A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in August 2024 with multiple diagnoses including anoxic brain injury (damage to the brain caused by lack of oxygen to the brain) and bipolar disorder (a mental health disorder that causes mood swings).
A review of Resident 1's Minimum Data Set (MDS-a Federally mandated assessment tool), Cognitive Patterns, dated 9/5/24, indicated Resident 1 had Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 1 was cognitively intact.
A review of Resident 1's SBAR [Situation, Background, Assessment, Recommendation] & Initial COC [Change of Condition]/Alert Charting & Skilled Documentation, dated 9/18/24, indicated .Unwitnessed resident to resident altercation occurred today at 1010 [10:10 a.m.]. Residents were separated immediately. [Resident 1] noted with skin tear to left upper arm .Per [Resident 1], [Resident 2] entered bathroom and grabbed arm .
A review of Resident 1's Care Plan, initiated 9/18/24, indicated .Focus .Altercation .Interventions .Monitor for any psychological effect from the altercation i.e. expression of fear, self isolation, sleep disturbance .
A review of Resident 1's Care Plan, initiated 9/18/24, indicated .Focus .Scratches Location: left upper arm .Interventions .Keep site clean and dry .
A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in October 2021 with multiple diagnoses including Alzheimers disease (a progressive disease that destroys memory and mental functioning), mood disturbance (mental health condition that causes changes in a person's emotional state) and anxiety (mental disorder causing worry and fear).
A review of Resident 2's MDS, Cognitive Patterns, dated 7/18/24, indicated Resident 1 had a BIMS score of 11 out of 15 that indicated Resident 2 had moderate cognitive impairment.
A review of Resident 2's SBAR & Initial COC/Alert Charting & Skilled Documentation dated 9/18/24, indicated .Resident noted with aggressive behavior towards another resident. Event was unwitnessed by staff. Residents were immediately separated. [Resident 2] was noted as the aggressor and sustained no injury .Per [Resident 1], [Resident 2] entered bathroom and grabbed arm .
A review of Resident 2's Care Plan, initiated 2/28/24, indicated .Focus . Resident is making statements that this is her house .Interventions . Approach in a calm manner .Do not force resident to comply against his/her wishes .
A review of Resident 2's Care Plan, initiated 9/18/24, indicated .Focus .Altercation .Interventions .Will redirect and remind resident that this facility is a home for all residents .
During an interview on 9/20/24 at 11:27 a.m. with the Administrator (ADM) and the Infection Preventionist (IP), the ADM stated an unwitnessed incident occurred between Resident 1 and Resident 2 on 9/18/24. The ADM stated Resident 1 and Resident 2 were not in the same room but did share an adjoining bathroom. The ADM stated Resident 1 was in the bathroom and was scratched by Resident 2. The ADM stated Resident 2 thinks people are in her space and house and did not like that Resident 1 was in her space. Resident 1 had a scratch on left upper arm.
During a concurrent observation and interview on 9/20/24 at 11:48 a.m. with Resident 1, observed an approximately one-inch red scratch on Resident 1's left upper arm. Resident 1 stated yesterday or the day before a man came into the bathroom when she was washing her hands or on the way out. Resident 1 stated, He grabbed my arm, said I couldn't use the bathroom, that it was his bathroom only. Resident 1 stated, Told them to let go. Resident 1 stated her arm bled at the time. Resident 1 stated, Felt violated in my own space.
During an interview on 9/20/24 at 11:58 a.m. with Resident 2, Resident 2 stated, Know I own the place. Resident 2 stated she was in the bathroom; someone came in and wanted to kill her. Resident 2 stated, Don't like people doing things to harm me. I bought this home. No one else is supposed to use the bathroom. Don't remember grabbing anyone's arm.
During an interview on 9/20/24 at 12:04 p.m. with Certified Nursing Assistant (CNA)1, CNA 1 stated Resident 2 thinks she owns the whole place and doesn't like anyone in her room. CNA 1 stated that they have to get Resident 2's permission to have someone else in her room.
During an interview on 9/20/24 at 12:11 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 2 scratched Resident 1's left arm on 9/18/24. LN 1 stated Resident 2 does not like anyone in her room and Resident 1 in the bathroom may have set her off.
During a telephone interview on 9/20/24 at 12:30 p.m. with LN 2, LN 2 stated she was notified of the incident between Resident 1 and Resident 2 on 9/18/24. LN 2 stated Resident 1 had a scratch on left upper arm. LN 2 stated Resident 2 has dementia and believed she was in her own house and believed that Resident 1 was in her house unannounced.
During a telephone interview on 9/20/24 at 12:42 p.m. with CNA 2, CNA 2 stated she heard commotion in Resident 1's room on 9/18/24. CNA 2 entered the adjoining bathroom, Resident 1 and Resident 2 were slapping at each others arms. CNA 2 stated Resident 2 was telling Resident 1, Get out of my house. CNA 2 stated Resident 2 does not want to share a bathroom. CNA 2 stated Resident 1 had a bleeding scratch on her arm.
A review of the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, indicated .Residents have the right to be free from abuse .This includes but is not limited to freedom from physical abuse .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objective .Protect residents from abuse .by anyone including .other residents .
A review of the facility's P&P titled Resident-to-Resident Altercations, revised 9/22, indicated .All altercation, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator .Behaviors that may provoke a reaction by residents or others include .wandering into others rooms/space .
A review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 4/21, .All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies .and thoroughly investigated by facility management .
Sept 2024
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure two of 20 sampled residents (Resident 11 and Resident 20) had an informed consent for the use of antipsychotic medications (drugs th...
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Based on interview and record review, the facility failed to ensure two of 20 sampled residents (Resident 11 and Resident 20) had an informed consent for the use of antipsychotic medications (drugs that mainly treat psychosis-related conditions and symptoms), when:
1. Resident 11's antipsychotic informed consent was not updated every six months; and,
2. Resident 20 had no informed consent for an antipsychotic.
This failure decreased the facility's potential to ensure residents or their responsible person(s) were fully informed of the risks, benefits, and alternative treatment options prior to the use of an antipsychotic medication.
Findings:
A review of Resident 11's admission Record, inidcated Resident 11 was admitted to the facility in 2021 with diagnoses including depression (a serious medical illness that negatively affects how you feel, the way you think and how you act) and bipolar disorder (a mental health condition that causes extreme mood swings). The record further indicated Resident 11's sister was the Responsible Party (RP, a person designed to make healthcare decisions for the resident).
A review of Resident 11's Order Summary Report, dated 9/5/24, indicated Resident 11 had orders for aripiprazole (antipsychotic medication) 15 milligrams (mg, a unit of measurement) by mouth one time a day for bipolar disorder. Resident 11 had buspirone (an antianxiety medication) 100 mg by mouth at bedtime and venlafaxine (a depression medication) extended release (cannot be crushed) 75 mg by mouth in the morning for crying spells.
A review of Resident 11's Verification of Informed Consent Physical Restraint & Psychotropic Medications, dated 6/16/21, indicated Resident 11 had informed consent for buspirone, aripiprazole, and venlafaxine in 6/16/21.
During an interview on 9/6/24 at 10:42 a.m. with the Director of Nursing (DON), the DON was aware Resident 11's informed consents for the psychotropic medications were last obtained in 2021 and confirmed informed consents needed to be updated every six months.
A review of the facility's policy titled, Informed Consent, dated 6/2021, indicated, .Obtaining informed consent is the responsibility of the licensed healthcare practitioner acting within the scope of his/her professional licensure performs . The policy further stipulated, The facility staff shall verify the resident or his/her surrogate has given informed consent . prior to the initiation of psychotherapeutic drugs .
A review of Resident 20's admission Record, indicated Resident 20 was admitted in October 2023 with diagnoses including dementia (a decline in cognitive abilities that affects a person's ability to think, remember, and perform daily activities), psychotic disturbance, and schizophrenia (serious mental illness that affects a person's thoughts, feelings, and behaviors).
A review of Resident 20's Minimum Data Set (MDS; a tool used to assess the health status of residents in nursing homes), dated 6/19/24, indicated Resident's 20 Brief Interview on Mental Status (BIMS) score was four out of 15 with severe cognitive impairment.
A review of Resident 20's Physician's Order Summary Report, indicated on 12/8/23 Resident 20 was orderd half tablet, 25 mg of quetiapine fumarate (a medication used to treat certain mental/mood disorders) by mouth two times a day for schizophrenia manifested by paranoia (the irrational and persistent feeling that people are out to get you or that you are the subject of persistent, intrusive attention by others), striking out, auditory hallucinations (hearing voices) informed consent by medical doctor.
A review of Resident 20's Medication Administration Record, dated 8/24, indicated Resident 20 was receiving half tablet of quetiapine 25 mg by mouth two times a day for schizophrenia.
A review of Resident 20's MD progress notes, dated 8/26/24, indicated an informed consent for quetiapine was not completed.
A review of Resident 20's Psychiatric Visit Progress Report, indicated Resident 20 was seen by a psychiatrist on 5/10/23 and 8/11/23.
A review of Resident 20's electronic record indicated there were no progress notes that indicated an informed consent had been obtained by the physician nor by the psychiatrist.
During an interview on 9/4/24 at 3:30 p.m., with Licensed Nurse 5 (LN 5), LN 5 stated licensed nurses might not start residents on antipsychotic medications until the physician had obtained an informed consent from the resident or RP. LN 5 further stated the physican was in charge of explaining and obtaining the informed consent for the prescribed antipsychotic and the licensed nurse should have called or talked to the resident or the RP to ensure the discussion occurred with the prescriber on the new medication and if they agreed to the medication and once this was confirmed then the medication can be started as prescribed to the resident.
During an interview on 9/4/24 at 4:25 p.m., with the DON, DON stated the practice in the facility was the physician who ordered the antipsychotic medication must obtain the informed consent from the resident or RP. The physician will then document the informed consent was obtained in the clinical record of the resident. The informed consent has to be verified by the licensed nurse and then the medication or treatment can begin. DON further stated in general nurses could not give the medication unless the informed consent was verified, or in case of an emergency the physician will be notified and the physician might approve for the medication to be given.
During an interview on 9/4/24 at 10 a.m. with the DON, DON stated there was no informed consent completed from 12/8/2023 through 9/3/24 for Resident 20. DON confirmed Resident 20 was started on quetiapine since 12/8/2023 through 9/3/24 without a duly completed informed consent. DON further stated an informed consent should had been verified before the administration of any antipsychotic medication.
During an interview on 9/4/24 with the Quality Services Consultant (QCS), QSC stated nurses could not begin an antipsychotic medication without an informed consent being obtained by the physician and residents must have an informed consent before beginning the antipsychotic medication unless it was an emergency. QSC further stated the expectations were licensed nurses must verify with the resident or the RP that an informed consent was discussed, and completed by the physician.
A review of facility's policy and procedure titled, Informed Consent, revised June 2021, indicated: 1. The facility shall ensure the resident's rights are maintained and a copy of these rights and pertinent policies are made available to the resident and to any representative of the resident. Among these rights under this section are the right to: a. Receive in advance all information that is material to a decision to accept or refuse treatment, Guidelines 2. The facility staff shall verify the resident or his/her surrogate has given informed consent to the proposed treatment or procedure prior to the initiation of psychotherapeutic drugs, antipsychotic drugs .
A review of an All Facilities Letter (AFL) 24-07 dated February 28, 2024 indicated: .Effective January 1, 2024, AB (Assembly Bill) 48 codifies existing regulations that state residents have the right to be free of psychotherapeutic drugs .Examination and Signatures .Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain informed written consent signed by the resident or or the resident's representative along with, the signature of the health care professional declaring the required material has been provided .Medical records .The signed written consent must be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures .Renewals of Informed Consents .Facilities must renew the written informed consent every 6 months .Updates to Federal Regulations for SNFs [Skilled Nursing Facility], ICFs [Intermediate Care Facility] and Hospices [specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life] .AB 48 updates references to Federal regulations found in the HSC [Health and Safety Codes] section 1599.1(i)(2). The updated references align with the 2017 version of Title 42 of the Code of Federal Regulations (CFR).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a baseline care plan (instructions needed to provide effective and person-centered care for the resident developed with...
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Based on observation, interview and record review, the facility failed to ensure a baseline care plan (instructions needed to provide effective and person-centered care for the resident developed within 48 hours of admission) for one of 20 sampled residents (Resident 331), when Resident 331's baseline care plan did not include an indwelling urinary catheter (IUC; a medical device that drains and collects urine from the bladder).
This failure had the potential to place Resident 331 at risk for unmet care needs.
Findings:
A review of Resident 331's admission record indicated Resident 331 was admitted to the facility in August of 2024 with diagnoses that included urinary tract infection (when bacteria multiply in the urinary tract [kidneys, ureters, bladder and/or urethra]), sepsis (a severe response to infection which can lead to organ damage) and chronic kidney disease (when kidneys are damaged and can't filter blood properly).
During an observation on 9/3/24 at 10:29 a.m., in Resident 331's room, Resident 331 was walking with use of a walker in his room while an IUC drainage bag was hanging from the walker.
A review of Resident 331's Order Summary Report, dated 9/4/24, indicated Resident 331 had an active order for an IUC and was started on 8/19/24.
A review of Resident 331's care plans, initiated 8/19/24, did not indicate any care plan for an IUC.
During an interview on 9/4/24 at 4:11 p.m. with Licensed Nurse 3 (LN 3), LN 3 stated if a resident had an IUC then she would expect the resident's care plan to indicate it, so staff will know the care the resident required.
During a concurrent interview and record review on 9/4/24 at 4:24 p.m. with the Director of Staff Development (DSD), Resident 331's care plan was reviewed. The DSD confirmed Resident 331's care plan did not indicate Resident 331 had an IUC. The DSD confirmed Resident 331 was admitted with an IUC and she expected the IUC to be reflected on the resident's baseline care plan. The DSD added, the care plan is used to communicate to staff the care a resident needed and if an IUC was not on the care plan, staff might not know that an IUC existed or what care the resident needed related to it.
During an interview on 9/6/24 at 10:43 a.m., with the Assistant Director of Nursing (ADON), ADON stated care plans were important to provide guidance on how to care for the resident and expected a resident's IUC to be on the baseline care plan.
A review of facility policy and procedure titled, Care Plans-Baseline, dated March 2022, indicated, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . the baseline care plan includes instructions needed to provide effective, person-centered care of the resident . and must include .but not limited to the following .physician orders .the baseline care plan is used until the staff can conduct the comprehensive assessment and develop a .comprehensive care plan (no later than 21 days after admission) .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to revise and implement a communication care plan for one of 20 sampled Residents (Resident 20) who did not speak English.
This fa...
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Based on observation, interview and record review the facility failed to revise and implement a communication care plan for one of 20 sampled Residents (Resident 20) who did not speak English.
This failure increased Resident 20's potential to receive inadequate and inaccurate care.
Findings:
A review of Resident 20's admission Record, indicated she was admitted with diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), apraxia (a neurological disorder that makes it difficult to perform purposeful movements or tasks, even though the person understands the request and is willing to do it).
During an observation on 9/3/24 at 11:24 a.m., Resident 20 was sitting in her wheelchair. The Department was unable to communicate with Resident 20 in English. Resident 20 was observed communicating in a different language and had no communication board in her room.
During an interview on 9/3/24 at 11:26 a.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated he was assigned to Resident 20. CNA 4 confirmed Resident 20 spoke a different language and would communicate by gesturing. CNA 4 stated he communicated with Resident 20 by gesturing and she seemed to understand. CNA 4 was not certain what language Resident 20 was speaking. CNA 4 stated he could not find the communication board and if needed Resident 20 had a relative who worked in the dietary department and would be asked to interpret for the staff.
During an interview on 9/3/24 at 11:35 a.m. with the Licensed Nurse 4 (LN 4), LN 4 confirmed Resident 20 spoke a different language and would communicate by gestures. LN 4 communicated with Resident 20 using gesturing. LN 4 was aware of a relative that worked in the kitchen who would be the interpreter and was not sure about the language Resident 20 was speaking. LN 4 was not aware if the facility had any translator services available.
During an interview on 9/3/24 at 1:30 p.m. with the Director of Staff Development (DSD), DSD stated there were a language communication board and translator services available via phone. The translation services book had listed as Mien and translation services were available 24 hours a day seven days a week via phone.
A review of Resident 20's Electronic Health Record (EHR) Resident Detail indicated Resident 20 spoke Laotian.
During an interview on 9/4/24 at 2:30 p.m. with the Dietary Aide 2 (DA 2), DA 2 stated she had the same last name as Resident 20 but they were not relatives. DA 2 spoke the same language as Resident 20 and would help out whenever she was at work. DA 2 confirmed she was not the official interpreter for the facility and was only helping out when it came to interpreting.
A review of Resident 20's care plan identified on 10/3/20, indicated Resident 20 had a psychosocial well-being problem related to problem solve and had language barrier. Care plan interventions indicated to increase communication between resident/family caregivers about care and living environment.
During an interview on 9/5/24 at 3 p.m. with the Director of Nursing (DON), DON stated for residents with language communication problems who could not speak English, the staff if they spoke the resident's language would be asked to act as an interpreter. The use of a translation service interpreter was available 24 hours a day via phone. DON confirmed Resident 20 had a language barrier and some command of English and had a relative that would act as an interpreter. Other helpful tools would be a communication board at the resident's bedside and could be obtained from the activities department. The DON confirmed and stated the interpreter services and the language interpreter services via phone were not part of Resident 20's care plan interventions. The DON also confirmed the care plan was last revised on 10/3/2020 and the interpreter services should have been part of the interventions.
A review of facility policy titled, Translation and/or Interpretation of Facility Services, revised 11/2020, indicated: .This facility's language access program will ensure that individuals with limited Engligh proficiency (LEP) shall have meaningful access to informationand services provided by the facility .When encoutering LEP individuals, staff members will conduct the initial language assessment (e.g., I Speak Cards) and notify the staff person in charge of the language access problem.
A review of facility's policy tiltled, Care Plans, Comprehensive Person - Centered, revised 3/22, indicated: .A comprehensive, person centered care plan that include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for two of 20 sampled residents (Res...
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Based on observation, interview, and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for two of 20 sampled residents (Resident 331 and Resident 135) when:
1. Resident 331's peripherally inserted central catheter intravenous line (PICC IV: used to deliver medications into a vein over a long period of time) flushes (a procedure that uses a mixture of salt and water to clear an IV line and reduce the risk of infection) were not documented in accordance with professional standards; and,
2. Resident 135's urinary drainage bag was not enclosed in a privacy bag, the urinary drainage bag collection tube was not kept properly positioned and kept free from kinks for optimal drainage.
These failures decreased the facility's potential to prevent worsening of the residents' clinical condition.
Findings:
1. A review of Resident 331's admission record, indicated Resident 331 was admitted to the facility in August of 2024 with diagnoses that included urinary tract infection (UTI: when bacteria multiplies in the urinary organs), sepsis (a severe response to infection which can lead to organ damage), and chronic kidney disease (when kidneys are damaged and can't filter blood properly).
A review of Resident 331's Order Summary Report, dated 9/4/24, indicated an order for Resident 331's PICC IV to be flushed every shift.
During an interview on 9/4/24 at 2:49 p.m. with Licensed Nurse 5 (LN 5), LN 5 stated the nurse who performed a PICC IV flush was expected to document they did it. LN 5 added, it was not acceptable for a nurse who did not perform the flush to document that another nurse had done it.
During an interview on 9/4/24 at 4:11 p.m. with LN 3, LN 3 stated when a nurse gave a medication then that same nurse should have documented giving the medication and it was not acceptable for a nurse who did not give the medication to document it was given.
During a concurrent interview and record review on 9/4/24 at 4:24 p.m. with the Director of Staff Development (DSD), Resident 331's August 2024 medication administration record (MAR) and August 2024 progress notes were reviewed. The DSD confirmed the MAR indicated the PICC IV flush scheduled for 10 p.m. on dates 8/20-8/31/24 indicated a code nine on each date. The DSD stated code nine meant there should be a progress note related to the administration. The DSD reviewed Resident 331's progress notes from 8/21/24 through 8/31/24 and confirmed the progress notes indicated a nurse documented either a different nurse had done the flush or the other nurse would do the flush. The DSD stated she expected the nurse who administered a medication or flush to document they gave it on the resident's MAR. The DSD confirmed it was not acceptable for one staff member to document that another staff member gave a medication or flush.
During a concurrent interview and record review on 9/6/24 at 10:43 a.m. with the Assistant Director of Nursing (ADON), Resident 331's August 2024 MAR and August 2024 progress notes were reviewed. The ADON confirmed from 8/20/24-8/31/24 the 10 p.m. PICC IV flush was documented code nine and corresponding notes indicated a nurse had documented that another nurse had either administered the PICC IV flush or would administer the PICC IV flush. The ADON acknowledged the documentation related to the flushes were not aligned with facility expectations, and the nurse who administered a medication or flushed must document they did it. The ADON confirmed the documentation did not align with professional standards expected of nurses.
A review of facility's policy and procedures (P&P) titled, administering medications, dated April 2019, indicated, . medications are administered in a safe and timely manner, and as prescribed . Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so medications are administered in accordance with prescriber orders . the individual administering the medication initials the resident's MAR on the appropriate line after given each medication .
A review of the facility's P&P titled, Peripheral and Midline IV catheter Flushing and Locking, dated March 2022, indicated, .document procedure in treatment administration record .2. A review of Resident 135's admission Record, indicated Resident 135 was admitted to the facility with diagnoses of pneumonia (lung infection), urinary retention, and the presence of a urine catheter.
During an observation on 9/3/24 at 12 p.m. Resident 135 had a foley catheter (a flexible tube that drains urine from the bladder into a bag outside the body) which was connected to a drainage bag. The drainage bag was draining amber colored clear urine and was found hanging on the resident's top bedside rail. The head of the bed was elevated approximately 30 - 35 degrees. The drainage bag was positioned higher than the resident's bladder, this prevented the free flow and drainage of urine from the bladder. There was no privacy bag to conceal the urinary drainage bag from view. Also, the drainage bag's collecting tubing was found to be kinked near the drainage bag. The presence of a kink in the collecting tubing prevented the free flow of urine into the drainage bag.
During an interview on 9/3/24 at 1230 p.m., with Certified Nurse Assistant 3 (CNA 3), CNA 3 stated Resident 135's drainage bag must be enclosed in in a privacy bag and confirmed the drainage bag must not be hanging from the top siderail and must be hanging lower than the resident's bladder. CNA 3 also stated the drainage bag must be below the level of the bladder of the resident and confirmed a kinked urine collection tubing. CNA 3 stated the kink in the collecting tubing, prevented the flow of urine into the drainage bag.
During a concurrent interview on 9/6/24 at 11:19 a.m. with the Director of Nursing (DON), (ADON) and the Quality Services Consultant (QSC), they all confirmed the expectations were all the residents' foley drainage bags must be positioned lower than the level of the resident's bladders. The urinary drainage bag must be off the floor, and should have no kinks in the collecting drainage tube. All urinary drainage bags must be covered with a privacy bag.
Review of the facility policy titled, Catheter Care, Urinary, revised 9/14, indicated: .Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter tubing free of kinks. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the bladder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide a communication board or use translator during assisting care for one resident (Resident 1) of 20 sampled residents. ...
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Based on observation, interview, and record review, the facility failed to provide a communication board or use translator during assisting care for one resident (Resident 1) of 20 sampled residents.
This failure decreased the facility's potential to meet Resident 1's ability to communicate her basic needs.
Findings:
A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility in 2022 with diagnoses including depression (a serious medical illness that negatively affects how you feel, think, and act).
A review of Resident 1's undated care plan titled, [Resident 1] has a communication problem [related to] language barrier. Primary language is Portuguese, indicated the interventions were: Listen attentively and allow ample time to communicate. Provide communication board. Utilize help of a translator or interpreter if applicable.
During a concurrent observation and interview on 9/3/24 at 9:03 a.m. with Certified Nursing Assistant 2 (CNA 2) in Resident 1's room, CNA 2 confirmed she did not use translator nor communication pictures to communicate with her, but rather used body language, gesture or pointing to objects.
During an interview on 9/3/24 at 12:01 p.m. with Resident 1's son, Resident 1's son stated Resident 1 spoke Portuguese and the facility's staff did not communicate well with Resident 1 and did not use the translator.
During an interview on 9/6/24 at 8:39 a.m. with Licensed Nurse 4 (LN 4), LN 4 stated she used English and Spanish when speaking to Resident 1. LN 4 stated she used the son as a translator and did not use a translator service.
During an interview on 9/6/24 at 10:40 a.m. with the Director of Nursing (DON), the DON stated the facility staff should have used communication board or phone translator when assisting Resident 1 with her daily living.
A review of facility's policy titled, Translation and/or Interpretation of Facility Services, dated 11/2020, indicated, The facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. The policy further stipulated, Family members and friends shall not be relied upon to provide interpretation services for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
2. A review of Resident 331's admission record indicated Resident 331 was admitted to the facility in August of 2024 with diagnoses that included, urinary tract infection (when bacteria multiply in th...
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2. A review of Resident 331's admission record indicated Resident 331 was admitted to the facility in August of 2024 with diagnoses that included, urinary tract infection (when bacteria multiply in the urinary organs), sepsis (a severe response to infection which can lead to organ damage) and chronic kidney disease (when kidneys are damaged and can't filter blood properly).
A review of Resident 331's order summary report, dated 9/4/24, indicated an active order for .Assess PICC line on (RUA) [right upper arm] for S/S of infection QS and notify MD if noted (Ensure all lumens have injection caps, lumens not in use are clamped) QS every shift .
A review of Resident 331's PICC IV care plan, initiated 8/19/24, indicated, .Risk for infection R/T [related to] catheter direct access to blood .interventions . Visually inspect I.V. [PICC IV] site QS, note any redness, swelling, pain or drainage, gently palpate areas around the insertion site for tenderness, phlebitis, inflammation or infiltration .
During an interview on 9/4/24 at 2:49 p.m. with LN 5, LN 5 stated registered nurses (RNs) are expected to assess a PICC IV site and to document it was done in the residents' MAR.
During an interview on 9/4/24 at 4:11 p.m. with LN 3, LN 3 confirmed RNs are responsible for PICC IV site assessments and were expected to document the assessment was done in the residents' MAR.
During a concurrent interview and record review on 9/4/24 at 4:24 p.m. with the Director of Staff Development (DSD), Resident 331's August 2024 MAR was reviewed. The DSD confirmed Resident 331's August MAR indicated the PICC IV site was expected to be assessed for signs and symptoms of infection on each shift and there was no documentation that the PICC IV site was assessed on the following scheduled dates and times: 6 a.m. on 8/25/24, 2 p.m. on 8/19-8/24/24, 8/26/24, 8/28/24, and 8/31/24, and 10 p.m. 8/19-8/31/24. The DSD stated the lack of documentation for those dates and times indicated the assessments were not done as ordered by the doctor.
During a concurrent interview and record review on 9/6/24 at 10:43 a.m. with the Assistant Director of Nursing (ADON), Resident 331's August 2024 MAR was reviewed. The ADON confirmed Resident 331's PICC IV site assessments were not done as ordered by Resident 331's doctor and the missing assessments put Resident 331 at higher risk of getting an infection to the PICC IV site.
A review of the facility's policy and procedure titled, Central Venous Catheter Care and Dressing Changes, revised March 2022, indicated, .the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infection that are associated with contaminated, loosened, soiled, or wet dressings . perform site care and dressing change at established intervals assessment observe insertion site and surrounding area for complications documentation .should be recorded in the resident's medical record .
Based on observation, interview, and record review, the facility failed to ensure two of 20 sampled residents (Resident 282 and Resident 331) who had Vascular Access Devices (VAD, thin flexible tube that provides access to veins for the delivery of IV [Intravenous, administered into a vein] medications) received the necessary care and services when:
1. Resident 282's Midline catheter (a type of VAD used for intravenous treatments of more than six days) was not monitored for signs and symptoms of infection every shift as ordered; and,
2. Resident 331's peripherally inserted central catheter intravenous line (PICC IV: a type of VAD used to deliver medications into a vein over a long period of time) was not monitored for signs and symptoms of infection every shift as ordered.
These failures placed the residents at risk for VAD related infections.
Findings:
1. A review of Resident 282's clinical record indicated he was admitted to the facility summer of 2024 with multiple diagnoses that included cellulitis (potentially serious bacterial skin infection) of the left lower limb.
During an observation on 9/3/24 at 9:23 a.m. in Resident 282's room, Resident 282 was lying in bed with midline IV at left upper arm and dressing intact. Resident 282 stated he was getting IV antibiotics for his left leg cellulitis.
A review of Resident 282's Order Summary, dated 8/28/24, indicated Assess midline site for S/S [signs/symptoms] of infection QS [every shift] and notify MD [Medical Doctor] if noted (Ensure all lumens have injection caps, lumens not in use are clamped) .
A review of Resident 282's care plan indicated, Resident is on IV Medications r/t [related to] left leg cellulitis .Check dressing at site as ordered .Monitor and report to MD PRN [as necessary] s/sx [signs and symptoms] of infection at the site: drainage, inflammation, swelling, redness, warmth .
A review of Resident 282's Medication Administration Record (MAR) indicated to Assess midline site for S/S of infection QS and notify MD if noted (Ensure all lumens have injection caps, lumens not in use are clamped) QS every shift . MAR further indicated from 8/28/24 to 9/4/24, out of 23 shifts, nine shifts were not signed as ordered.
During a concurrent interview and record review on 9/5/24 at 9:19 a.m. with Licensed Nurse 6 (LN 6), LN 6 confirmed Resident 282's administration record to assess midline IV site every shift had nine shifts with no signature. LN 6 stated it should have been signed.
During a concurrent interview and record review on 9/5/24 at 10:30 a.m. with the Director of Nursing (DON), DON confirmed Resident 282's administration record to assess IV midline had shifts that were not signed. DON stated, If the order says it's every shift, then it should be signed every shift. When asked if the order was not signed does it mean it was not done, the DON did not answer.
During an interview on 9/5/24 at 11:15 a.m. with the Infection Preventionist (IP), IP stated he expected the midline IV to be monitored for signs and symptoms of infection every shift. IP stated midline IV was an easy portal of entry for infections that could affect Resident 282 because the route of entry for infection was faster.
A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, .Each resident's comprehensive person-centered care plan is consistent with the resident's rights to .receive the services and/or items included in the plan of care .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of 20 sampled residents (Resident 281) who received hemodialysis (HD, a medic...
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Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of 20 sampled residents (Resident 281) who received hemodialysis (HD, a medical procedure that helps remove waste and excess fluid from the blood when the kidneys are unable to perform this function), when her output was not accurately measured as ordered.
This failure increased Resident 281's risk in developing fluid overload.
Findings:
A review of the clinical record indicated Resident 281 was admitted to the facility in summer of 2024 with multiple diagnoses that included end stage renal disease (ESRD, permanent kidney failure that requires a regular course of dialysis or a kidney transplant) and fluid overload.
During a conccurent observation and interview on 9/3/24 at 1:10 p.m. in Resident 281's room, Resident 281 was eating lunch. She stated she was feeling tired the day after HD, was urinating in the bathroom and was continent.
A review of Resident 281's Order Summary dated 8/30/24, indicated to record intake and output (I&O) in milliliters (ml; a unit of measure) every shift for fluid restriction and if Resident 281 was incontinent to put the number of incontinence episodes.
A review of Resident 281's care plan indicated, ESRD with interventions that included monitor fluid restrictions as ordered and monitor intake and output .
A review of Resident 281's Medication Administration Record (MAR) for Fluid restriction l&O: Record intake & output QS [every shift] . from 8/30/24 to 9/4/24 indicated, Resident 281's output was marked as x number of times urinated and not the amount of output in ml.
During a concurrent interview and record review on 9/5/24 at 9:19 a.m. with Licensed Nurse 6 (LN 6), LN 6 stated Resident 281 was continent. Resident 281's MAR for fluid restriction I&O was reviewed and LN 6 stated [Resident 281] was using the toilet, so I just asked for the number of times she went to the toilet. LN 6 confimed the order for I&O and stated because she is continent there should be an amount of output there . if [Resident 281] is incontinent you can write the number of times she was changed .
During a concurrent interview and record review on 9/5/24 at 10:35 a.m. with the Director of Nursing (DON), Resident 281's MAR for fluid restriction I&O was reviewed. The DON stated staff should have entered the amount of the output because it was in the order.
A review of facility's policy titled, Output, Measuring and Recording, revised October 2010, indicated .Verify that there is a physician's order for this procedure .The following information should be recorded on the bedside intake and output record and/or in the resident's medical record .The amount (in mLs) of output .
A review of facility's policy titled, End-Stage Renal Disease, Care of a Resident with, revised September 2010, indicated Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one resident (Resident 11) out of 20 sampled residents received proper monitoring for psychotropic medication (any drug that affects...
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Based on interview and record review, the facility failed to ensure one resident (Resident 11) out of 20 sampled residents received proper monitoring for psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) when there was no manifestation, no diagnosis identified, and no side effect monitoring for Resident 11's buspirone (an antianxiety medication).
These failures placed Resident 11 at risk for unnecessary psychotropic medication use side effects.
Findings:
A review of Resident 11's admission Record, indicated Resident 11 was admitted to the facility in 2021 with diagnoses including depression (a serious medical illness that negatively affects how you feel, the way you think and how you act) and bipolar disorder (a mental health condition that causes extreme mood swings).
A review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 6/20/24, indicated Resident 11 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating her cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was mildly impaired.
A review of Resident 11's Order Summary Report, dated 9/5/24, indicated Resident 11 had buspirone 100 milligram (a unit of measure) by mouth at bedtime. There was no diagnosis, manifested by, and side effect monitoring for buspirone in the orders.
During a concurrent interview and record review on 9/5/24 at 9:53 a.m. with the Medical Record Director (MRD), the MRD confirmed she did not see documentation of the side effect monitoring for buspirone in the Medication Administration Record.
During an interview on 9/6/24 at 9:07 a.m. with the Director of Nursing (DON) and Assistant DON (ADON), the ADON confirmed a psychotropic medication should have a diagnosis, manifested by or evidence by, and inform consent and stated without diagnosis, manifested by, and inform consent, the order would be an incomplete order. ADON further stated the resident or family member would not know why the resident is taking the psychotropic medication.
A review of the facility's policy titled, Psychotropic Medication Use, dated 7/2022, indicated, Psychotropic medication management includes: indications for use and monitoring of behavior . adequate monitoring for efficacy and adverse consequences .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to maintain an essential kitchen equipment in good working order and repair for a census of 81, when freezer number (#) six was ob...
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Based on observation, interview and record review the facility failed to maintain an essential kitchen equipment in good working order and repair for a census of 81, when freezer number (#) six was observed to have an internal temperature of 10 degrees Fahrenheit (a unit of measure for temperature) and was not in good repair.
This failure had the potential for residents to become sick from food borne illnesess.
Findings:
During a concurrent observation and interview on 9/3/24 at 8:25 a.m. with the Certified Dietary Manager (CDM) in the kitchen dry storage area, freezer # six was inspected and the thermometer inside the freezer indicated the temperature was 10 degrees Fahrenheit. A box of turkey ham was stored in the freezer and was rock hard to touch. CDM confirmed the thermometer indicated 10 degrees Fahrenheit and stated the freezer temperature must be kept at zero degrees Fahrenheit or lower. CDM further stated Freezer # six's door seals were not forming a tight seal. Freezer # six had an accumulation of frost inside the top part of the freezer. CDM stated a latch at the bottom part of the freezer door was needed so it can be in closed and locked position and to ensure a tight seal was maintained. CDM confirmed freezer # six's seals were loose and there was a built-up of frost in the freezer because of the inadequate seal and stated she regularly had been removing the frost built up and a new freezer was needed.
A review of the facility's policy titled, Food Storage, dated 1/1/17, indicated: .Frozen foods shall be stored and displayed in their frozen state unless being thawed in accordance with the current Food Code.
A review of the Food and Drug Administration article titled, Refrigerator Thermometers - Cold Facts about Food Safety, dated 3/5/24, indicated To ensure that your refrigerator is doing its job, it is important to keep its temperature at 40 °F[Fahrenheit] or below; the freezer should be at 0 °F.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of a census of 81 residents, when the emergency Kit (E-Kit, limited number ...
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Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of a census of 81 residents, when the emergency Kit (E-Kit, limited number of medications for use in an emergency) log was not filled out for two opened E-Kits.
This failure increased the potential for the facility to not have the needed medications available during emergencies that could jeopardize residents' health and safety.
Findings:
During a concurrent observation and interview on 9/4/24 at 10:01 a.m. with Licensed Nurse 3 (LN 3), stations one and two medication storage rooms had three E-Kits with injectable medications (medications to be administered by injection into the vein or muscle) with blue plastic locks. LN 3 stated the three E-kits with blue locks were recently opened. LN 3 confirmed two out of three E-kits were not logged in the E-kit log. LN 3 stated she does not know when the two E-kits were opened and the yellow form inside it were to be filled out and faxed to the pharmacy letting them know the E-kits were opened, then the yellow form will be placed in the binder and the white form should be placed inside the E-kits. LN 3 confirmed there were no yellow forms for the 3 opened E-kits in the binder.
During a concurrent interview and record review on 9/4/24 at 10:30 a.m., the Assistant Director of Nursing (ADON) verified, the 2 opened E-kits were not logged in the E-Kit log.
During an interview on 9/5/24 at 10:23 a.m., with the Director of Nursing (DON), DON stated she expected the staff to fill out the E-kit log form as soon as they took out the medication.
A review of the facility's policy titled, Emergency Pharmacy Service and Emergency Kits, dated 2007, indicated .Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy with the original prescriber order or refill request form and placed within the resealed emergency kit until it is scheduled for exchange. The hard copy will be retained in the nursing care center .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure medications were labeled, stored, and disposed of consistently according to standards of practice for a census of 81, w...
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Based on observation, interview and record review, the facility failed to ensure medications were labeled, stored, and disposed of consistently according to standards of practice for a census of 81, when:
1. Expired medications were not removed from the medication cart and the medication storage room;
2. Pharmaceutical products were found in the medication storage room and the medication cart without an opened date;
3. Pharmaceutical products with an unclear and torn label was found in a medication cart;
4. Loose medications were found in a medication cup in the first drawer of the medication cart; and,
5. A white powdered medication in medication cups were left unattended at the resident's bedside.
These failures had the potential to result in the lack of effectiveness of the medications, increase the potential for medication administration errors and jeopardize residents' health and safety.
Findings:
1.During a concurrent observation and interview on 9/4/24 at 10:01 a.m. with Licensed Nurse 3 (LN 3), in station one and two medication storage room there was an opened bottle of pantoprazole suspension (medication to treat high levels of stomach acid) with a discard date of 7/10 in the medication refrigerator. LN 3 stated, It's [pantoprazole] past the date .should have been discarded.
During a concurrent observation and interview on 9/4/24 at 12:36 p.m. with LN 1, in station one medication cart two, LN 1 confirmed there was an opened regular insulin(a medication used to control high blood sugar) 100 units/milliters (u/ml; a unit of measure) vial with an opened date of 7/22/24 and labelled to discard after 31 days. LN 1 stated the insulin should have been discarded on 8/22/24.
During an interview on 9/5/24 at 10:35 a.m. with the Director of Nursing (DON), DON stated if the medication was expired, then it should have been destroyed.
A review of the facility's policy titled, Medication Labeling and Storage, revised February 2023, indicated, .Multi-dose vials that have been opened or accessed .are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial .
2. During a concurrent observation and interview on 9/4/24 at 10:01 a.m. with LN 3, in station one and two medication storage room, LN 3 confirmed there was an opened vial of tuberculin purified protein derivative (PPD, solution used to help diagnose tuberculosis) without an opened date and discard date.
During a concurrent observation and interview on 9/4/24 at 12:36 p.m. with the Quality Services Consultant (QSC), in station one medication cart two, QSC confirmed there was an opened umeclidinium (a medication to treat chronic obstructive pulmonary disease) 62.5 micrograms (mcg; a unit of measure) inhaler and an opened fluticasone furoate/vilanterol (a medication to treat asthma; a lung disease) 100mcg/25mcg inhaler without an opened date and discard date.
During a concurrent observation and interview on 9/4/24 at 1:09 p.m. with LN 1, in station one medication cart two, LN 1 confirmed there was a bottle of valproic acid (a medication to treat seizures or mental or mood problems) 250 milligrams (mg; a unit of measure)/five ml oral solution and a bottle of lactulose (a medication used to treat constipation) 10 grams (g: a unit of measure)/15ml solution without opened date and discard date.
During an interview on 9/5/24 at 10:23 a.m. with the DON, DON stated when the staff opens the medication it should be dated on the date it was opened.
A review of the facility's policy titled, Administering Medications, revised April 2019, indicated, .When opening a multi-dose container, the date opened is recorded on the container .
A review of the facility's policy titled, Medication Labeling and Storage, revised February 2023, indicated, .Multi-dose vials that have been opened or accessed .are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial .
3. During a concurrent observation and interview on 9/4/24 at 12:36 p.m. with QSC, in station one medication cart two, QSC confirmed there was an opened albuterol sulfate (a medication to treat asthma) 90 mcg inhaler with a torn label and an opened budesonide and formoterol fumarate dihydrate (a medication to treat asthma) 160 mcg/4.5 mcg inhaler with a torn and unclear label.
A review of the facility's policy titled, Medication Labeling and Storage, revised February 2023, indicated, .1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions .8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items .
4. During a concurrent observation and interview on on 9/4/24 at 1:14 p.m. with LN 7, in station three medication cart three, a medication cup with two blue and white colored capsules and one pink colored tablet were found in the first drawer of the cart. LN 7 stated she was supposed to discard the capsule and the tablet. LN 7 further stated the capsules were empty and the pink tablet fell out of the pack and she was going to waste it later in the medication room at station one medication disposal bin.
During an interview on 9/5/24 at 10:23 a.m. with the DON, DON stated loose pills should be thrown in the drug buster (a medication disposal system that uses a solution to deactivate or dissolve medications) in the medication cart. DON further stated loose and opened pills are not supposed to be kept in the medication cart and should be disposed immediately in the drug buster.
A review of the facility's policy titled, Medication Labeling and Storage, revised February 2023, indicated, 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .2. The nursing staff is responsible for maintaining medication storage .in a safe manner .11. Medications may not be transferred between containers .
5. During an observation on 9/3/24 at 12:26 p.m. in a resident's room, there were white powdered medications in two cups placed at resident's bedside.
During an interview on 9/3/24 at 12:33 p.m. with LN 3, LN 3 confirmed the white powdered medication should not be at the resident's bedside and stated it should have been stored in the medication cart or treatment cart. LN 3 further stated there were residents who wander in the facility and they could have access to the medication if not stored properly.
During an interview on 9/6/24 at 1:28 p.m. with the DON, DON confirmed the medication should have been stored and locked in the cart or medication room to prevent other residents from getting it.
A review of the facility's policy titled, Medication Labeling and Storage, dated 2/2023, indicated The facility stored all medications and biological in locked compartments .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to accurately check and test sanitizing solutions in the kitchen for a census of 81, when:
1. The dishwasher sanitizing solution w...
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Based on observation, interview and record review the facility failed to accurately check and test sanitizing solutions in the kitchen for a census of 81, when:
1. The dishwasher sanitizing solution was not accurately checked for effectiveness; and,
2. The Quatenary Ammonium Compound (QAC; a type of chemical that is used to kill bacteria, viruses, and mold) was not tested at the right temperature and concentration.
These failures had the potential to expose residents to foodborne illnesses from improperly sanitized eating utensils served with the residents' meals.
Findings:
1. During a concurrent observation and interview with the Registered Dietitian (RD) and the Dietary Aide 1 (DA 1) on 9/4/24 at 1:34 p.m. in the kitchen, the dishwashing activity was observed. DA 1 stated she was doing the dishwashing and the dishwashing machine was a low temperature dishwasher. DA 1 also stated she did not know what should the low temperature dishwashing machine's minimum operational temperature be. The temperature gauge of the machine while operating was observed and registered a temperature of 110 degrees Fahrenheit (a unit of temperature measurement). DA 1 demonstrated how the sanitizing solution was checked to ensure it was at an effective concentration level, stated the sanitizing solution used was Chlorine, took a test strip and placed it into the liquid collected at the bottom of the machine. DA1 confirmed the Chlorine testing indicated a reading of 100 parts per million (ppm; described concentrations of chemicals dissolved in a solvent, typically water) after she compared it with the testing bottle's colored bars.The test strips container's color bars were observed to be faded and hard to read. The test strips container expiration date was also faded and difficult to visualize. DA 1 confirmed that the test strips container's color bars were faded and the expiration date was not visible and stated she compared the color to as close as she could to the faded color bars. RD confirmed the color bars were faded and the expiration date of the test strip container was also faded and difficult to read and stated the accuracy of the Chlorine test would be hard to visually verify the accuracy of the readings.
2. During a concurrent observation and interview with DA 1 on 9/4/24 at 1:34 p.m. in the kitchen, DA 1 demonstrated how to wash dishes with a three compartment sink. DA 1 stated QAC was used for the sanitation of dishes and the disinfection of the kitchen surfaces with a red bucket container. DA 1 conducted testing with a test strip after mixing a QAC solution and water form a QAC mixing station. DA 1 dipped the QAC test strip for 10 seconds and read the result, which was 400 ppm. The QAC testing strip instructions from the manufacturer were to dip the chemical strip into the formula at a temperature of 65 to 75. DA 1 measured the temperature in the QAC red bucket using the kitchen's digital thermometer which indicated 63 degrees Fahrenheit. DA 1 confirmed the solution was tested in cold water and was below the manufacturer's recommendation for testing.
Duirng an interview on 9/4/24 at 2 p.m. with the RD, RD stated the QAC chemical test strip per manufacturer's recommendation must be tested at a minimum temperature of 65 degrees Fahrenheit. The temperature reading was verified with the RD and was below the manufacturer's recommendation. RD confirmed the QAC testing result was at 400 ppm and stated the manufacturer's recommendation must be followed to ensure the accuracy of the readings.
A review of the Food and Drug (FDA) 2022 Food Code section 4-501.116 on Warewashing (dishwashing) Equipment, Determining Chemical Sanitizer Concentration it indicated that the effectiveness of chemical sanitizers is determined primarily by the concentration and pH of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the concentration of the chemical sanitizer solution. The FDA Food Code further explained in section 4-703.11 on Hot Water and Chemical Sanitation that Efficacious sanitization depends on warewashing being conducted within certain parameters. Time is a parameter applicable to both chemical and hot water sanitization. The time hot water or chemicals contact utensils or food-contact surfaces must be sufficient to destroy pathogens that may remain on surfaces after cleaning. Other parameters, such as rinse pressure, temperature, and chemical concentration are used in combination with time to achieve sanitization.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
2. A review of Resident 331's admission record, indicated Resident 331 was admitted to the facility in August of 2024 with diagnoses that included, urinary tract infection (UTI; when bacteria multiply...
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2. A review of Resident 331's admission record, indicated Resident 331 was admitted to the facility in August of 2024 with diagnoses that included, urinary tract infection (UTI; when bacteria multiply in the urinary organs), sepsis (a severe response to infection which can lead to organ damage), and chronic kidney disease (when kidneys are damaged and can't filter blood properly).
A review of Resident 331's Order Summary Report, dated 9/4/24, indicated Resident 331 had an active order that started on 8/19/24 for an indwelling urinary catheter (IUC: a medical device that drains and collects urine from the bladder) and a peripherally inserted central catheter intravenous line (PICC IV: a long thin tube put into a vein used to deliver medications over a long period of time).
During an interview on 9/4/24 at 1:52 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated a timely set up of personal protective equipment (PPE: supplies, such as gloves, gowns, face masks, goggles, to minimize exposure to hazards) and signage indicating a resident was on a transmission based precaution (TBP: the use of additional PPE is required when a resident is suspected or known to be infected or a carrier of a transmissible agent) or EBP was important. CNA 2 added if TBP/EBP were not set up timely, staff could be going in and out of the room without use of recommended PPE and risk the spread of germs to residents and staff.
During a concurrent observation and interview with Resident 331 on 9/4/24 at 2:13 p.m., outside Resident 331's room was a posted sign indicating Resident 331 was on EBP and listed the recommended PPE to wear when assisting him. Next to the door was a cart with PPE supplies. Resident 331 stated he had been in the facility for over two weeks and was placed on EBP today.
Duirng an interview on 9/4/24 at 2:27 p.m. with CNA 7, CNA 7 stated residents with indwelling medical devices would be put on EBP and staff relied on the nurse who processed the resident's admission to set up TBP/EBP signage and supplies when indicated, so staff would know how to prevent the spread of infections while working with the resident.
During an interview on 9/4/24 at 3:02 p.m. with the IP, the IP stated EBPs were important in controlling the spread of infections in the facility and the facility will implement EBP for residents with indwelling medical devices such as an IUC and PICC IV. The IP confirmed Resident 331 was admitted over two weeks ago with a PICC IV and IUC but had not been put on EBP until today. The IP acknowledged the best practice was to initiate EBP as soon as possible to limit the spread of infection and Resident 331's EBP should have been implemented sooner.
A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated August 2022, indicated, . enhanced barrier Precautions (EBPs) are used as an infection prevention and control intervention .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not apply .EBPs are indicated for residents with wounds and/or indwelling medical devices . the EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical devices that places them at increased risk .
3. A review of Resident 335's admission record, indicated Resident 335 was admitted to the facility in August of 2024 with diagnoses that included heart disease, muscle weakness, and UTI.
A review of Resident 335's minimum data set (MDS: an assessment tool), dated 8/21/24, indicated Resident 335 did not have memory problems and required staff supervision and assistance with personal hygiene including washing hands.
A review of Resident 335's care plan, initiated 8/17/24, indicated, [Resident 335] is a high risk for infection . interventions .observe good hand hygiene .
During an observation on 9/3/24 at 11:48 a.m., in the communal dining room, Resident 335 was sitting at a table when facility staff asked Resident 335 to return to her room and Resident 335 left the dining room. At 11:59 a.m. Resident 335 returned to dining room and sat at a table waiting for lunch while no staff offered to assist Resident 335 with hand hygiene. At 12:06 p.m. Resident 335 was served her lunch meal.
During an interview on 9/3/24 at 12:09 p.m., Resident 335 stated staff had not helped her or ensured she performed hand hygiene prior to serving her lunch.
During an interview on 9/3/24 at 12:10 p.m. with Restorative Nursing Assistant 1 (RNA 1), RNA 1 stated staff were expected to offer residents hand sanitizer prior to meals. RNA 1 further stated staff had just forgot today to offer Resident 335 hand sanitizer when she returned.
During an interview on 9/3/24 at 12:19 p.m. with RNA 2, RNA 2 acknowledged when a resident left the dining room and came back, the resident should have been offered hand sanitizer before eating.
During an interview on 9/6/24 at 12:08 p.m. with CNA 3, CNA 3 stated he is often assigned to work in the dining room during lunches. CNA 3 confirmed staff were expected to offer and or assist residents with hand hygiene prior to getting served their food to prevent residents from getting sick.
During an interview on 9/6/24 at 12:12 p.m. with the IP, IP stated he expected staff to offer residents hand hygiene prior to meals for infection prevention purposes.
A review of the facility's P&P titled, 'Handwashing/Hand Hygiene, dated August 2019, indicated, .this facility considers hand hygiene the primary means to prevent the spread of infections .all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in prevention the transmission of healthcare-associated infections use an alcohol-based hand rub or, alternatively, soap . and water for the following situations .before and after eating or handling food .
4. During a concurrent observation and interview on 9/3/24 at 10:31 a.m. with the Maintenance Director (MD), the kitchen's ice machine was inspected. On the top panel of the ice machine there was a white plastic covering the cascading water portion of the ice machine, the plastic cover was lifted up and exposed the left and right bottom portions of the ice machine. A white paper napkin was used to wipe the bottom left and right side portions of the ice machine. The bottom right and left hand corner of the ice machine was observed to have the presence of a blackish colored material that adhered to the white paper napkin. MD confirmed the findings found on the white paper napkin and stated the blackish growth should not be there and the ice machine was not clean.
During an interview on 9/3/24 at 10:45 a.m. with the Administrator (ADM) and the Certified Dietary Manager (CDM), CDM confirmed the presence of the blackish growth and stated it should not be there and the ice machine was not clean. ADM also confirmed the blackish growth that was on the white napkin.
A review of facility's policy and procedure, titled Ice Machines and Ice Storage Chests, revised 1/12, indicated: .Ice machines and ice storage/ distribution containers will be used and maintained to assure a safe and sanitary supply of ice .Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions.
Based on observation, interview, and record review the facility failed to follow infection control practices for a census of 81 when:
1. Laundry Aide (LA) did not maintain hand hygiene practices while handling clean and soiled linen in the laundry;
2. Enhanced based precautions (EBP) were not initiated timely for Resident 331's indwelling medical devices;
3. Staff did not ensure Resident 335 performed hand hygiene before being served lunch on 9/3/24; and
4. The ice machine was not properly cleaned.
These failures had the potential to spread infection among residents.
Findings:
1. During an observation on 9/5/24 at 12:10 p.m. with LA at the laundry area, LA was handling cleaned linen with gloved hands. There was no hand hygiene prior to wearing gloves to handle clean linen. Then LA removed gloves and put on new gloves, gown, and face mask to handle soiled linen. There was no hand hygiene performed after removing and putting on gloves. While handling soiled linen, LA removed gloves and put on new gloves in three different occasions and did not perform hand hygiene practices.
During an interview on 9/5/24 at 12:30 p.m. with LA, LA confirmed she did not perform hand hygiene practices before touching clean linen, before donning and after removing gloves. LA stated there could be a contamination of soiled and clean linen.
During an interview on 9/6/24 at 10:33 a.m. with the Infection Preventionist (IP), the IP expected staff to wash hand or use hand sanitizer prior to put on and removing gloves.
A review of the facility's policy titled, Department (Environmental Services) - Laundry and Linen, dated 1/2014, indicated Wash hands after handling soiled linen and before handling clean linen. The policy further stipulated, Always wash hands after completing the task and removing gloves. Wash hands before handling clean linen.
A review of the facility's policy titled, Handwashing/Hand Hygiene, dated 8/2019, indicated, Hand hygiene is the final step after removing and disposing of personal protective equipment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure six residents (Resident 14, 26, 30, 38, 42, and 51) out of 20 sampled residents had call lights (equipment used by a pat...
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Based on observation, interview and record review the facility failed to ensure six residents (Resident 14, 26, 30, 38, 42, and 51) out of 20 sampled residents had call lights (equipment used by a patient to alert or communicate with a caregiver) within easy reach or call lights that were operable.
This failure had the potential for residents to be unable to contact nursing staff when needed.
Findings:
A review of Resident 51's admission Record, indicated Resident 51 was admitted to the facility in October 2021 with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
During a concurrent observation and interview on 9/3/24 at 10:37 a.m. with Resident 51, in Resident 51's room, Resident 51's call light was observed coiled on the wall where the call light attaches, broken, without a button to push. Resident 51 statedvI don't know where my call light is.
During a concurrent observation and interview on 9/3/24 at 12:58 p.m. with Certified Nursing Assistant 9 (CNA 9), in Resident 51's room, CNA 9 confirmed Resident 51's call light was out of reach and inoperable. CNA 9 stated It doesn't work, the button is broken.
A review of Resident 51's care plan indicated Resident 51 was at risk for falls and staff needed to place call light within easy reach.
A review of Resident 42's admission Record, indicated Resident 42 was admitted to the facility in April 2023 with diagnoses which included senile degeneration of the brain (loss of intellectual ability).
During a concurrent observation and interview on 9/3/24 at 10:55 a.m. with Resident 42, in Resident 42's room, Resident 42's call light cord was observed wrapped around the bed rail hanging off the right side of the bed close to the floor. When questioned if Resident 42 could reach the call light, Resident 42 stated, I can't find the call light, they should have that where I can reach it.
During a concurrent observation and interview on 9/3/24 at 11 a.m. with CNA 9, in Resident 42's room, CNA 9 confirmed Resident 42's call light was not easily within reach.
A review of Resident 42's care plan indicated Resident 42 was at risk for falls and staff needed to be sure the resident's call light is within reach and encourage the resident to use it.
A review of Resident 14's admission Records, indicated Resident 14 was admitted to the facility in February 2022 with diagnoses which included hemiplegia (paralysis on one side of the body) and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).
During an observation on 9/3/24 at 3:35 p.m. in Resident 14's room, Resident 14 was unable to locate the call light. Resident 14 attempted to locate the call light in the bed; however, with contractures (limited range of motion) to Resident 14's right hand, Resident 14 was unable to locate the call light on the right side of the bed.
During a concurrent observation and interview on 9/3/24 at 3:40 p.m. with CNA 6 in Resident 14's room, CNA 6 was unable to locate Resident 14's call light. CNA 6 had to dig under two of Resident 14's pillows to locate the call light. CNA 6 stated, [Resident 14's] right hand is very contracted and needs the call light closer to [Resident 14's] left hand.
A review of Resident 14's care plan indicated Resident 14 was at risk for falls and injuries and to keep call light within reach. Resident 14's care plan also indicated Resident 14 had a self-care deficit and to [keep] call light within reach and answer promptly.
A review of Resident 38's admission Record, indicated Resident 38 was admitted to the facility in March 2023 with diagnoses which included encephalopathy (any brain disease that alters brain function or structure) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe).
During a concurrent observation and interview on 9/3/24 at 3:47 p.m. with CNA 5 in Resident 38's room, CNA 5 confirmed that Resident 38 did not have a call light available.
During a concurrent observation and interview on 9/3/24 at 4:06 p.m., with the Maintenance Director (MD) in Resident 38's room, the MD confirmed Resident 38 did not have a call light. The MD stated, Call lights that aren't working or if the resident doesn't even have one, I should be notified immediately.
A review of Resident 38's care plan indicated Resident 38 had a risk for further falls due to poor or no safety awareness and to place the call light within easy reach and to remind [Resident 38] to call for assistance.
A review of Resident 30's admission Record, indicated Resident 30 was initially admitted to the facility in August 2023 with diagnoses which included COPD and diabetes mellitus, type 2 (DM II, a long-term condition in which the body has trouble controlling blood sugar and using it for energy).
During a concurrent observation and interview on 9/3/24 at 3:53 p.m., with CNA 5, in Resident 30's room, CNA 5 confirmed Resident 30's call light was broken and inoperable. CNA 5 stated, There's no button, there should be a button.
A review of Resident 30's care plan, indicated Resident 30 was found on the floor sitting next to her bed and wheelchair. The nursing staff initiated the following interventions to decrease Resident 30's risk for falls, Encourage to use call for help before attempting to transfer or ambulate .keep call light within reach and answer promptly.
A review of Resident 26's admission Record, indicated Resident 26 was initially admitted to the facility in March 2021 with diagnoses which included Huntington's disease (an inherited condition in which nerve cells in the brain break down over time) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).
During a concurrent observation and interview on 9/3/24 at 4:06 p.m. with the MD, in Resident 26's room, the MD confirmed Resident 26's call light was broken and inoperable. The MD stated, These call lights that aren't working should be reported to me immediately .this needs to be fixed immediately.
During an interview on 9/5/24 at 4:03 p.m. with the Director of Nursing (DON), the DON stated, Call lights are expected to be close to resident, within easy reach; and the call light needs to be working . without the call light residents would not be able to alert staff for their needs or if there was a safety concern.
A review of the facility's policy and procedure (P&P) titled, Call System, Resident, dated September 2022, indicated Each resident is provided with a means to call staff directly for assistance from his/her bed .the resident call system remains functional at all times.
A review of the facility's P&P titled, Answering the Call Light, dated September 2022, indicated Be sure that the call light is plugged in and functioning at all times .Ensure that the call light is accessible to the resident when in bed .and from the floor .Report all defective call lights to the nurse supervisor promptly.
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to protect the right to be free from abuse for 1 of two sampled residents (Resident 1) when Resident 1 was hit in the face by Re...
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Based on observation, interview, and record review, the facility failed to protect the right to be free from abuse for 1 of two sampled residents (Resident 1) when Resident 1 was hit in the face by Resident 2 causing a scratch to the bridge of the nose and bruise to the left eye.
This failure to protect Resident 1 resulted in a scratch to his nose and a bad bruise to the left eye.
Findings:
During a record review of Resident 1's Face Sheet (FS), the FS indicated, Resident 1 was admitted with diagnoses which included hemiplegia and hemiparesis (one-sided weakness) and aphasia (impairment of language).
During a record review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/29/24, indicated, Resident 1 had severe memory problems.
During a record review of Resident 1's Care Plan (CP) dated 8/14/24, the CP indicated, resident to resident physical altercation in [Resident 1's room] the victim and [Resident 2's room] the perpetrator.
During a record review of Resident 1's interdisciplinary team (IDT, a group of healthcare professionals from complementary fields who work in tandem to treat a patient), dated 8/14/24, the IDT indicated, [Resident 1] was involved in a resident to resident altercation. [Resident 1] was the victim and his roommate, [Resident 2] was the perpetrator. [Resident 2] hit [Resident 1] on the face with a [television] remote control causing injuries to his face. Per Charge Nurses Notes (CNN): [Resident 1] was resting in bed after [family members] left for the day. A staff member was walking by the resident's room when she saw the roommate [Resident 2] standing over him [Resident 1] with a [television] remote in his hand. Staff member stated that [Resident 2] had already struck [Resident 1] once before she got there but was able to stop Resident 2 from hitting Resident 1 again. The [nurse-writer] noticed the hematoma (blood collection from a burst blood vessel) in [Resident 1's] [left] eye and the scratch/redness to [Resident 1's] face. [Resident 1] began to get agitated and restless. [Resident 1] was sent out to the [local] hospital for further evaluation.
During a record review of Resident 1's hospital discharge diagnoses (HDD) dated 8/14/24, the HDD indicated, subconjuctival hemorrhage (blood vessel breaks in the white of the eye, which causes a bright red patch in the white of the eye), history of cerebro-vascular accident(CVA, stroke) with residual deficit and assault.
During an observation on 8/20/14 at 11:32 a.m., Resident 1's left eye's subconjuctival area was red.
During an interview on 8/20/24 at 11:32 a.m., with the Family Member (FM), the FM validated [Resident 1] was hit in the head by the roommate [Resident 2]. The FM stated [Resident 2] used the television remote control to hit [Resident 1] in the head.
During an interview on 8/20/24 at 12:23 p.m. with Resident 2, translated by the Occupational Therapist (OT), Resident 2 confirmed he hit Resident 1 on the face two to three times and used the television remote control. Resident 2 stated he hit Resident 1 due to the noise he created by shaking the bed siderail.
During an interview on 8/20/24 at 1:38 p.m., with the Speech Pathologist (SP), the SP validated he saw [Resident 2] at the head bed-part of [Resident 1] and was holding a television remote control. The SP stated, [Resident 2] had already struck [Resident 1]. The SP stated [Resident 2] admitted he struck [Resident 1] in the face using the television remote control.
During an interview, on 8/20/24 at 1:20 p.m., with the Director of Nursing (DON), the DON stated, no Resident deserves to be hit by television remote control in the face.
During an interview on 8/20/24 at 2 p.m., with the Social Services Director (SSD), the SSD stated, no Resident deserved to be hit by television remote control in the face. The SSD stated [Resident 1] was more agitated after the incident. The SSD also stated [Resident 1] was traumatized after he was hit by a television remote control in the face.
During a review of the facility's Policy and Procedure (P/P), titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, the P/P indicated, Residents have the right to be free from abuse .This includes but is not limited to freedom from .verbal, mental, .or physical abuse .
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the rights to be free from abuse for 1 of 3 s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the rights to be free from abuse for 1 of 3 sampled residents (Resident 2) when staff witnessed Resident 1 punched Resident 2 in the face during an altercation causing Resident 2's eyes to bleed.
This failure resulted in Resident 2 abused by Resident 1 and sustaining a bruise and a skin tear on the right eye.
Findings:
A review of Resident 1's admission record indicated he was admitted to the facility fall of 2022 with multiple diagnoses that included Dementia (impaired ability to remember, think, or make decisions) and history of traumatic brain injury.
A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/13/24, indicated, he had severe memory problems.
A review of Resident 1's undated care plan indicated as one of the interventions, Check resident at least every 2 hours and as needed for comfort and safety .
A review of Resident 1's Physician History and Physical, dated 6/17/24, indicated, .Assessment/Plan: Agitation .Continue to monitor .
A review of Resident 2's admission record indicated he was admitted to the facility fall of 2023 with multiple diagnoses that included Dementia and delusional disorders (paranoia). A review of Resident 2's MDS, dated [DATE], indicated he was exhibiting behaviors of delusions and hallucinations (apparent perception of something not present). Resident 2's MDS also indicated he had severe memory problems.
A review of Resident 2's undated care plan indicated, .Resident was involved in resident to resident altercation & obtained a skin tear/laceration to right side of eye .
A review of Resident 2's Physician History and Physical, dated 6/11/24 indicated, .Continue to monitor symptoms. Continue current medications and provide supportive care .
A review of Resident 2's SBAR [Situation, Background, Assessment, Recommendation] & INITIAL COC [change of condition] /ALERT CHARTING & SKILLED DOCUMENTATION dated, 8/11/24, indicated, At 1800 both residents sitting in the wheelchair in the hallway at station 3, close by room [ROOM NUMBER]. The victim [Resident 2] ran over his [Resident 1's] right foot, the victim he got mad [sic] then the abuser [Resident 1] punches him [Resident 2] right away the victim at the right side of eye, the victim sustained small cut and bleeding noted .
During a telephone interview on 8/14/24 at 11:49 a.m., the Certified Nursing Assistant 1 (CNA 1) stated, she and the other CNA were in the room changing a resident when they heard the Licensed Nurse 1 (LN 1) calling them for help because the two residents (Resident 1 and Resident 2) were fighting. The CNA 1 stated Resident 2 had redness on his right eye, and a skin tear.
CNA 1 stated, Resident 1 sometimes gets agitated, then he would punch someone and Resident 2 can be verbally aggressive at times. The CNA 1 further stated, In the memory care unit . we need to monitor them [the residents] closely because they have behaviors, so we need to monitor them . no one was there in the hallway when the incident happened .
During a concurrent observation and interview on 8/14/24 at 12:10 p.m., in the memory care unit hallway, Resident 2 was sitting in the wheelchair. Resident 2 was observed with a scratch on his nose and with reddish and bluish discoloration surrounding his right eye. A skin tear and blood clot on the right side of the eye (outer eyelid) approximately 1 inch in size was also observed.
During an observation on 8/14/24 at 12:14 p.m., in the memory care unit hallway, Resident 1 was wheeling himself towards Resident 2, Resident 1 then stood up facing Resident 2, looked agitated and was observed with closed fists swinging and demonstrating punching motion towards Resident 2.
During a telephone interview on 8/14/24 at 2:33 p.m., the CNA 2 stated we need to closely monitor the residents. CNA 2 stated, the altercation could have been prevented if they [the residents] were closely monitored. The CNA 2 stated, Resident 1 had aggressive behavior .he can hit you; he would stand up and hit
you .
During a telephone interview on 8/15/24 at 8:17 a.m., the Licensed Nurse 1 (LN 1) stated, Resident 1 and Resident 2 were both in the memory care unit hallway near room [ROOM NUMBER] when LN 1 saw Resident 2 run over Resident 1's right foot. LN 1 saw Resident 1 reacted, punching Resident 2 right away. The LN 1 stated Resident 2's right eye was bleeding, and he sustained a small laceration from the punch. The LN 1 stated, LN 1 was in the hallway near the nurse's station, a few feet away from room [ROOM NUMBER], when the altercation happened. The LN 1 stated, Resident 1 had an attitude of standing up and trying to punch you when you pass by him. The LN 1 further stated, residents in the memory care unit needed close monitoring and supervision because they have dementia. LN 1 stated, nobody was there to supervise the two residents in the hallway at that time.
During a telephone interview on 8/14/24 at 1 p.m., the Director of Nursing (DON) stated, the LN saw the altercation between the two residents. The DON stated, Resident 1 was very impulsive, he had history of aggression towards others. The DON further stated residents in the memory care unit needed close monitoring and supervision.
During a follow up interview on 8/16/24 at 2:18 p.m., the DON stated, she expected all patients to be free from abuse. She further stated, The incident could have been prevented .we have to protect our residents and the resident have the right to be free from abuse .
A review of Facility policy titled, Resident Rights, revised December 2016, indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . be free from abuse .
A review of Facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, Residents have the right to be free from abuse . by anyone including . other residents .Protect residents from abuse . by anyone including . other residents . Ensure adequate staffing and oversight/support .
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and policy record review, the facility failed to ensure medications were stored locked for the census of 82, when a medication cart (Med Cart 2) was left open and unat...
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Based on observation, interview, and policy record review, the facility failed to ensure medications were stored locked for the census of 82, when a medication cart (Med Cart 2) was left open and unattended in the hallway.
This failure had the potential for medication misuse and drug diversion.
Findings:
During a concurrent observation and interview on 8/1/24 at 11:17 a.m. with Licensed Nurse 1 (LN 1), the Medication Cart 2 was observed left opened and unattended in the hallway. There were other residents in their wheelchairs and staff near the medication cart.
LN 1 was not near the Medication Cart 2, but was sitting down and, on the phone, talking at the nursing station. LN 1 confirmed she was not aware the medication cart was unlocked and confirmed it should always be locked.
During an interview on 8/1/24 at 12:07 p.m. with the Director of Nursing (DON), the DON confirmed the expectation is staff members lock the medication cart when they are not attending to (close by) the cart. The DON further stated staff may not see residents sitting in wheelchairs because they are too low when staff is sitting at the nursing station.
During an interview on 8/1/24 at 12:10 p.m. with the DON and the Administrator (ADM), the ADM stated he would tell LN 1 to write a statement which indicated nurse was aware of the medication cart being unlocked.
A review of the facility's policy titled, Medication Labeling and Storage, dated 2/2023, stipulated, The facility stores all medications and biologicals are locked compartment . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biological are locked when not in use .
Based on observation, interview, and policy record review, the facility failed to ensure medications were stored locked for the census of 82, when a medication cart (Med Cart 2) was left open and unattended in the hallway.
This failure had the potential for medication misuse and drug diversion.
Findings:
During a concurrent observation and interview on 8/1/24 at 11:17 a.m. with Licensed Nurse 1 (LN 1), the Medication Cart 2 was observed left opened and unattended in the hallway. There were other residents in their wheelchairs and staff near the medication cart.
LN 1 was not near the Medication Cart 2, but was sitting down and, on the phone, talking at the nursing station. LN 1 confirmed she was not aware the medication cart was unlocked and confirmed it should always be locked.
During an interview on 8/1/24 at 12:07 p.m. with the Director of Nursing (DON), the DON confirmed the expectation is staff members lock the medication cart when they are not attending to (close by) the cart. The DON further stated staff may not see residents sitting in wheelchairs because they are too low when staff is sitting at the nursing station.
During an interview on 8/1/24 at 12:10 p.m. with the DON and the Administrator (ADM), the ADM stated he would tell LN 1 to write a statement which indicated nurse was aware of the medication cart being unlocked.
A review of the facility's policy titled, Medication Labeling and Storage, dated 2/2023, stipulated, The facility stores all medications and biologicals are locked compartment . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biological are locked when not in use .
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure complaints and grievances were documented as directed by their grievance policy and procedure for one of 3 sampled residents (Reside...
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Based on interview and record review, the facility failed to ensure complaints and grievances were documented as directed by their grievance policy and procedure for one of 3 sampled residents (Resident 1).
This failure had the potential for Resident 1's concerns not to be thoroughly investigated and resolved.
Findings:
A review of Resident 1's clinical records indicated she was admitted to the facility late 2021 with multiple diagnoses that included Alzheimer's Disease (brain disorder that affects memory, thinking and behavior).
A review of Resident 1's IDT [Interdisciplinary, a group of professional staff ]- CARE CONFERENCE & CARE PLAN dated 2/23/24 indicated, Spoke with RP [Responsible Party] .Here are the primary concerns we have re [regarding] her care and lack thereof at [name of facility]: : We call to speak with [Resident's name] and are told to hold for the transfer to her ward but no one ever responds and puts her on the phone .this has been for the past 2-3 months. We have not been able to speak to her .Last time we visited, [Resident 1's] personal hygiene was not good. Her clothing was not what we purchased for her and all the toiletries were gone. Are items being stolen from her .
During a concurrent interview and record review on 2/28/24 at 11:43 a.m., the Social Service Director (SSD) stated, during the last care conference, Resident 1's representative, complained about multiple things regarding Resident 1's care and grooming. The SSD stated, the sisters complained that Resident 1 had missing toiletries. She stated she checked Resident 1's belongings and the items were not there. The SSD stated, she did not think she placed social services notes or filled out a grievance form for the family. She stated she should have documented it [grievance]. Upon review of the grievance log, SSD verified she did not document anything in the grievance log.
A review of the facility policy titled, Grievances/Complaints, Recording and Investigating, revised April 2017 indicated, .2. Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the Allegations . 5. The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: a. The date the grievance/complaint was received; b. The name and room number of the resident filing the grievance/complaint (if available); c. The name and relationship of the person filing the grievance/complaint on behalf of the resident (if available); d. The date the alleged incident took place; e. The name of the person(s) investigating the incident; f. The date the resident, or interested party, was informed of the findings; and g. The disposition of the grievance (i.e., resolved, dispute, etc.) .
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision of two residents (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision of two residents (Resident 1 and Resident 2) of three sample residents when Resident 2 allegedly pushed Resident 1, resulting in Resident 1's fall and experiencing pain, swelling and hematoma (bad bruise, an injury that causes blood to collect and pool under the skin).
This failure decreased the facility's potential to ensure sufficient staff monitoring of residents to ensure resident safety.
Findings:
A review of an admission Record indicated Resident 1 was re-admitted to the facility late 2022 with multiple diagnoses which included dementia (loss of cognitive functioning - thinking, remembering, and reasoning) difficulty walking and history of falling. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/17/23, indicated moderate memory problems.
A review of an admission Record indicated Resident 2 was admitted to the facility late 2022 with multiple diagnoses which included dementia, and traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head). Resident 2's MDS, dated [DATE], indicated very severe memory problems.
During a review of Resident 1's SBAR [a situational report] & INITIAL COC [change of condition]/ALERT CHARTING & SKILLED DOCUMENTATION, dated 8/9/23 at 9 a.m., on 8/9/23 at 8:20 a.m., Resident 1 stated she had a fall due to Resident 2 who pushed her in the dining room while she was walking. The SBAR indicated, .upon assessment 2x 2 cm [centimeter, a unit of measurement] bump was noted on the back of her head and resident saying, it hurts a lot .
During a review of Resident 1's care plan dated 11/23/22, indicated, . Risk Factors: High risk for agitation, injuries, falls, ADL declines, Increased behaviors, Has issues with anger .Goal .maintain safety . Resident 1's care plan dated 12/20/22, indicated, .Anticipate . the resident's needs.
During a review of Resident 2's care plan, dated 6/19/23, indicated, .Resident's Decision Making Ability is considered as: Severely impaired .Check resident .as needed for .safety .Anticipate resident's needs.
During an observation on 8/16/23, at 12 p.m., in the memory unit (secured unit for residents with memory problems), there were 3 staff present, one Licensed Nurse (LN) and two Certified Nursing Assistants (CNAs).
During a concurrent observation and interview on 8/16/23, at 12:08 p.m., in the memory unit dining room, Resident 1 was sitting in a chair, watching television, walker on the side. When asked, Resident 1 said she remembered falling on the floor and hurting her head.
During an interview on 8/16/23 at 12:10 p.m., CNA 2 stated, Me and my partner [CNA 1] were in another room changing a resident when we heard a 'thump' sound, we came in right away into the dining room, saw the resident [1] already on the floor .
During an interview on 8/16/23 at 12:15 p.m., CNA 1 stated, We were in room [ROOM NUMBER], heard screaming and a big 'thump' sound like someone fell to the floor, ran as fast as we can, [Resident 1] was on the floor, facing up, [Resident 2] was standing next to [Resident 1] looking at her .prior to the incident, [Resident 2] was in the dining room in the corner and [Resident 1] was with her walker walking in the dining room .
During an interview on 8/16/23, at 12:18 p.m., when asked what intervention decreased the likelihood of resident-to-resident altercation in the memory unit, the LN 2 stated, .continuous monitoring, extra help from other staff .
During an interview on 8/22/23, at 10:02 a.m., LN 1 stated, .I assessed the resident [1] and there was a bump and hematoma on the back of her head. Resident [1] speaks Spanish only, through a student nurse translating for us .the resident stated she was walking in the dining room, and the other resident [Resident 2] got up from his chair then [Resident 2] pushed her, and she fell to the floor .
During an interview on 8/22/23, at 10:41 a.m., the Director of Nursing (DON) stated, it was the expectation that, There is always staff watching the residents .
During an interview on 8/22/23, at 11 a.m., the DON stated she expected at least one staff member to always watch the residents to protect each resident from other residents' potential aggression and ensure each resident's safety. The DON also stated the Charge Nurse was passing medications, the Activity Aide was on break, and both of the CNAs were helping another resident when the alleged altercation happened.
A review of the facility's policy and procedure titled, Secured Unit Evaluation and Placement, revised October 2022, indicated, The facility shall place a resident into a secure unit .ensuring the safety of the resident and others.
A review of the facility's policy and procedure titled, Safety and Supervision of Residents, revised July 2017, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .
Aug 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure services provided met professional standards when:
Staff did not follow physician orders when they cleaned Resident 16's indwelling ...
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Based on interview and record review, the facility failed to ensure services provided met professional standards when:
Staff did not follow physician orders when they cleaned Resident 16's indwelling catheter (a tubing that collects urine attached to a drainage bag).
This failure decreased the potential to provide effective care and services that meet the nursing standards of quality.
Findings:2. A review of a physician's order dated 6/22/23 indicated for staff to cleanse Resident 16's indwelling catheter site with water and soap, rinse then pat dry every shift (morning (AM), evening (PM), and nocturnal (NOC)).
During a concurrent interview with the Medical Records Director (MRD) and record review of Resident 16's Treatment Administration Record (TAR) on 8/3/23 at 3:10 p.m., the TAR indicated no charting and no LNs initials on 3/24/23 PM shift, 3/26/23 NOC shift, 3/31/23 PM shift, 3/31/23 NOC shift, 5/3/23 AM shift, 5/12/23 PM shift, 5/20/23 NOC shift, 5/21/23 NOC shift, 6/23/23 PM shift, and 7/15/23 AM shift. The MRD confirmed she was not able to verify if the order was carried out if it was not documented.
During an interview on 8/3/23 at 3:15 p.m., the Registered Nurse Supervisor (RNS) stated if it was not documented, it was not done.
During a concurrent interview and record review on 8/3/23, at 3:15 p.m., the DON acknowledged and confirmed, Yes, if not documented, it was not done.
During an interview on 8/4/23, at 10:40 a.m., the DON stated it was expected nurses follow and carry out all physician orders and to clarify if there were any questions on the order.
A review of the facility's P&P titled, Medication and Treatment Orders, revised July 2016, indicated, Orders .shall be administered .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician's order to clean an indwelling cat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician's order to clean an indwelling catheter (a tubing that collects urine attached to a drainage bag) for one resident (Resident 16) of 23 sampled residents for a census of 81.
This failure reduced the facility's potential to prevent urinary tract infections.
Findings:
During a review of an admission Record indicated Resident 16 was admitted to the facility on [DATE] with multiple diagnoses, which included major depressive disorder, and encounter of palliative care (care for life-limiting illness).
During a review of Resident 16's physician's order, dated 6/22/23, indicated nursing staff were to cleanse the indwelling catheter site with water and soap, rinse then pat dry every shift (morning (AM), evening (PM), and nocturnal (NOC)).
During a concurrent interview and record review on 8/3/23, at 3:10 p.m., with the Medical Records Director (MRD), Resident 16's Treatment Administration Record (TAR) indicated no charting and no LNs initials on the following dates and shifts:
3/24/23 PM shift,
3/26/23 NOC shift,
3/31/23 PM shift,
3/31/23 NOC shift,
4/1/23 NOC shift,
5/3/23 AM shift,
5/12/23 PM shift,
5/20/23 NOC shift,
5/21/23 NOC shift,
6/23/23 PM shift,
and 7/15/23 AM shift.
The MRD confirmed she was not able to verify if orders were carried out if they were not documented as done.
During a concurrent interview and record review on 8/3/23, at 3:15 p.m., the Director of Nursing (DON) acknowledged and confirmed, Yes, if not documented, it was not done.
During an interview on 8/3/23, at 3:45 p.m., the Infection Preventionist (IP) stated the purpose of cleaning the urinary catheter site with water and soap is to reduce the potential for urinary catheter infection. The IP acknowledged and confirmed it was not done and it was an infection control issue.
A review of the facility's policy and procedure (P&P) titled, Medication and Treatment Orders, revised July 2016, the P&P indicated, Orders .shall be administered .
During a review of the facility's P&P titled, Catheter Care, Urinary, revised September 2014, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure three residents (Resident 59, Resident 11, and Resident 21) out of 23 sampled residents received proper monitoring for psychotropic ...
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Based on interview and record review, the facility failed to ensure three residents (Resident 59, Resident 11, and Resident 21) out of 23 sampled residents received proper monitoring for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) when:
1. Resident 59 did not have orders to monitor behavior and side effects; and
2. Resident 21 was prescribed quetiapine (a psychotropic medication that affects the brain associated with mental processes and behavior) without appropriate indications for use, behavior, and medication side effects monitoring.
These failures placed the residents at risk for unnecessary psychotropic medication use.
Findings:
1. A review of Resident 59's admission record indicated Resident 59 was admitted in early 2023 with diagnoses including dementia with behavioral disturbances (exhibiting agitation, including verbal and physical aggression, wandering, and hoarding) and major depressive disorder.
A review of Resident 59's Minimum Data Set (MDS, standardized assessment tool) indicated Resident 59 had mild depression. The MDS indicated Resident 59 had physical and verbal behaviors towards others.
A review of Resident 59's Medication Administration Record (MAR), dated July 2023, indicated an order for sodium valproate 250 mg (milligrams, a unit of measurement) give 1 [one] tablet by mouth three times a day for dementia with behavioral disturbance m/b [manifested by] yelling out loud. The order's start date was 6/22/23. There was no order to monitor the target behavior or side effects of the use of the medication.
During a concurrent interview and record review on 8/4/23 at 8:36 a.m., with Licensed Nurse 7 (LN 7), Resident 59's electronic medical record was reviewed. The LN 7 confirmed there was no behavior or side effect monitoring for the scheduled sodium valproate in Resident 59's chart.
During a concurrent interview and record review, on 8/4/23, at 10:59 a.m., the Director of Nursing (DON) confirmed a resident receiving medication which included specific target behavior(s), those behaviors should have been monitored and monitoring for the potential side effects of the medication should have been documented.
During an interview on 8/4/23 at 2:46 p.m., the Consultant Pharmacist (CP) stated the facility staff should have behavior monitoring and side effect monitoring when a medication is used for altering behaviors.
2. A review of an admission Record indicated Resident 21 was admitted to the facility in June of 2017 with diagnoses that include dementia without behavioral, psychotic, mood or anxiety disturbance (loss of cognitive function and social skills).
A review of Resident 21's MDS indicated Resident 21 did not exhibit any behavioral symptoms (physical or verbal) from June 2018 to June 2023.
A review of the facility's care plan titled, The resident is on psychotropic medications r/t [related to] Schizophrenia, dated 5/22/20, indicated, staff to monitor, record and report side effects and adverse reactions of psychoactive medications to the Medical Director. Additionally, there was no documentation in Resident 21's record that staff were monitoring for side effects or adverse reactions to the medication.
During a concurrent interview and record review with the DON on 8/3/23 at 10:49 a.m., she confirmed there was no physician order to monitor behavior of striking out or monitor side effects for quetiapine.
During an interview with the MRD (Medical Records Director) on 8/4/23 at 8 a.m., the MRD confirmed there was no documentation for monitoring of behaviors: distress/delusions, hearing voices/auditory hallucinations, striking out and verbal aggression in Resident 21's medical record. The MRD also confirmed there was no documentation to show staff were monitoring for side effects or adverse reactions.
A review of the facility's policy titled, Antipsychotic Medication Use, revised in December 2016, indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medication .Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician .
A review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, revised 3/19, indicated, When medications are prescribed for behavioral symptoms, documentation will include .monitoring for efficacy and adverse consequences .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% when:
1. Resident 60 was administered crushed metoprolol (a medication to ...
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Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% when:
1. Resident 60 was administered crushed metoprolol (a medication to treat high blood pressure) XR [extended release] and omitted a dose of aspirin; and,
2. Resident 45 was administered isophane insulin (an intermediate-acting medication to lower blood sugar levels) without being rolled prior to administration.
These failures resulted in two medication errors and one omitted dose being identified out of 29 opportunities during an observation of medication administration which resulted a medication error rate of 10.34%.
Findings:
1. A review of Resident 60's admission Record indicated Resident 60 was admitted in early 2023 with diagnoses including palliative care (specialized medical care for people with a serious illness) and dysphagia (difficulty swallowing).
During a concurrent observation and interview on 8/1/23 at 8:11 a.m., during the medication pass with Licensed Nurse 1 (LN 1), LN 1 took 1 tablet of metoprolol 50 mg (milligrams, a unit of measurement) out of the bubble pack. The LN 1 stated she removed all Resident 60's medication and confirmed she had 5 tablets in the cup prior to administration of medications to Resident 60 which consisted of: 1 tablet of metoprolol, 1 tablet of hydralazine (a medication for high blood pressure), 1 tablet of losartan (a medication for high blood pressure) and 2 tablets of senna. The LN 1 then took all of Resident 60's medications in the cup and crushed them. The LN 1 mixed all Resident 60's medications in chocolate pudding and stated confirmed she completed preparation of Resident 60's medication.
After observing the LN 1 administer Resident 60's medication, a review of Resident 60's Medication Administration Record (MAR), dated August 2023, was conducted. Resident 60's MAR indicated the LN 1 had omitted a dose of 81 milligram of aspirin.
During an interview with LN 1 on 8/2/23 at 1:41 p.m., the LN 1 confirmed all medications for Resident 60 were crushed during observation on 8/1/23. The LN 1 further stated if a medication cannot be crushed it was indicated on the medication pack and on the order for the residents medication. The LN 1 confirmed the medication packet for Resident 60's metoprolol XR indicated, Do not chew or crush. The LN 1 stated the medication was not supposed to be crushed and the physician should have been called for a different medication.
2. A review of Resident 45's admission Record indicated Resident 45 was admitted in Spring 2022 with diagnosis that included type 2 diabetes mellitus with diabetic polyneuropathy (loss of nerves, increased sensitivity from high blood sugars).
During a concurrent medication pass observation and interview on 8/1/23 at 3:30 p.m., the LN 4 removed isophane insulin from the vial without having rolled the vial prior to inserting the syringe to draw up the dose. The LN 4 confirmed she did not roll the medication prior to administration.
During an interview with the DON on 8/4/23 at 10:59 a.m., the DON stated medications should be given as directed by the physician. The DON further stated extended-release medication cannot be crushed prior to administration. The DON stated the physician should be called for a different medication that can be crushed. DON further stated insulin should be rolled prior to administration to prevent high blood sugars.
During an interview with Consultant Pharmacist (CP) on 8/4/2023 at 2:46 p.m., the CP stated extended-release medication should not be crushed. The CP further stated crushed metoprolol XR could lower a residents blood pressure. The CP stated isophane insulin should be rolled prior to administration to prevent inconsistencies of medication administration.
A review of the facility's policy titled, Administering Medications, revised April 2019, indicated, Medications are administered in accordance with prescriber orders .The individual administering the medication checks the label THREE (3) times to verify . right route of administration before giving the medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices for a census...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices for a census of 81 when:
1. One of three medication carts was left unlocked;
2. Loose pills were found in two of two medication carts; and,
3. Outdated medication was found in two of two medication carts.
These failures had the potential to contribute to medication error, unsafe medication use and storage, and diversion.
Findings:
1. During an observation on [DATE] at 3:20 p.m., Licensed Nurse 4 (LN 4) was administering medication for a resident in room [ROOM NUMBER]. The medication cart was in the hallway and unlocked. The LN 4 was inside the resident's room with her back facing the medication cart.
During an interview on [DATE] at 3:23 p.m., LN 4 confirmed the medication cart should be locked when not in view.
During an interview with the Director of Nursing (DON) on [DATE] at 11 a.m., the DON confirmed the medication cart should be locked at all times when not in view.
During a review of the facility's policy titled, Storage of Medications, revised date [DATE], indicated, Unlocked medication carts are not left unattended.
A review of a facility policy titled, Administering Medications revised 4/19 indicated, During administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse.
2. During a concurrent observation and interview conducted on [DATE] at 2:12 p.m. with LN 2, the station 1 medication cart was inspected; three loose round pills were found. LN 2 confirmed there were three loose pills in the cart and they needed to be disposed of.
During a concurrent observation and interview conducted on [DATE] at 3 p.m. with LN 3, the station 3 medication cart was inspected. One loose round pill was found and LN 3 stated the medication should be disposed of in the drug buster (medication disposal system).
3. During a concurrent observation and interview conducted on [DATE] at 2:12 p.m. with LN 2, the station 1 medication cart was inspected. One vial of isophane insulin (an intermediate-acting insulin) had an open date of [DATE], LN 2 stated the medication was expired. One vial of regular insulin (a short-acting insulin) was opened on [DATE], LN 2 stated the medication was expired. One insulin pen for a resident was opened on [DATE], LN 2 stated the insulin pen expired within 14 days of opening. One eye drop medication had an open date of [DATE], LN 2 stated the eye drops should be disposed 30 days after opening.
During a concurrent observation and interview conducted on [DATE] at 3 p.m. with LN 3, the station 3 medication cart was inspected. One expired multi-dose insulin was opened on [DATE], LN 3 stated insulin can be used for 30 days after opening and was expired. LN 3 stated using expired insulin could cause the resident to receive an inaccurate or ineffective dosage.
During an interview with the DON on [DATE] at 10:59 a.m., the DON stated the expiration for insulin was 28 days to 30 days after being opened and removed from the fridge. DON stated expired insulin had the potential to be ineffective at lowering the resident's blood sugar, and should not be used.
During a review of a facility's policy titled, Storage of Medication revised [DATE] indicated, .outdated, or deteriorated drugs or biologics are returned to the dispensing pharmacy or destroyed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain confidential information when resident meal tickets were thrown in the regular trash.
These failures decreased the facility's pote...
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Based on interview and record review, the facility failed to maintain confidential information when resident meal tickets were thrown in the regular trash.
These failures decreased the facility's potential to prevent resident-identifiable information being accessible to the public.
Findings:
During a follow up tour and observation of the kitchen on 8/1/23 at 8:34 a.m. the Dish Washer Personnel (DWP) was observed cleaning the dirty dishes from the served breakfast meal. The DWP was observed scraping away food scraps and placing resident meal tickets into the regular trash. In a concurrent interview, the DWP confirmed she scraped away all the food items from the trays including the residents meal tickets and threw them together in the regular garbage. The DWP confirmed the meal tickets had the resident's name, room number, type of diet, food allergies and food dislikes. The DWP stated she was trained to throw all of these together in the regular trash.
In an interview with the Food Service Manager (FSM) on 8/1/23 at 8:35 a.m., the FSM confirmed the DWP scraped the food away and threw away residents' meal tray tickets in the regular trash. The FSM stated the meal tickets contained residents' information and should not be thrown away in the regular trash. The FSM stated, We always threw them away in the regular trash. The FSM also stated throwing the meal tickets into the trash was not the recommended method of disposal of the record.
In a review of that facility's document titled Destruction of Health Records indicated, .the health records may be destroyed in a manner which will permanently prevent the access to the health information contained in the record. This would include shredding, incineration, or pulverization.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain infection control practices de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain infection control practices designed to provide a safe and sanitary environment and help prevent the transmission of diseases and infections for a census of 81 when:
1. The Dietary Assistant (DA) used a gloved hand to rub her nose and continued to prepare lunch plates without washing her hands or putting on new gloves;
2. The Dietary Services Supervisor (DSS) refilled fresh butter sauce into a bottle with older butter sauce which had initially been filled 11 days prior;
3. Staff members did not use hand hygiene before and after providing resident care or during medications administration;
4. A juice dispensing machine spike was left uncovered;
5. The dry storage room was not maintained in a clean and sanitary manner;
6. The base of the bench can opener was not clean; and,
7. The ice machine was unsanitary in the kitchen.
These failures had the potential to result in transmission of infection in the facility and cause illness.
Findings:
1. During a concurrent observation and interview on 8/4/23 at 12:15 p.m., while serving lunch the DA used her gloved hand to rub her nose and continued to make a lunch plate and loaded it into the tray cart. The DA confirmed she had touched her face and stated should have stopped and changed her gloves.
An interview on 8/4/23 at 1:30 p.m. the DSS stated the DA should not have touched her face with a gloved hand and continued to prepare lunch plates. The DSS also stated the DA should have removed her gloves, washed hands, and put on new gloves for food safety.
A review of the facility's policy and procedure titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practice, revised November 2022, indicated, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness .Employees must wash their hands .during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when .after engaging in other activities that contaminate the hands .gloves are considered single-use .gloves are removed, hands are washed and gloves are replaced .the use of disposable gloves does not substitute for proper handwashing .
2. In an observation on 8/4/23 at 12:16 p.m. in the kitchen, the DSS removed a partially filled bottle labeled butter with the date 7/25 from the serving line. The DSS then opened a bulk bottle of a yellow liquid and poured it into the partially filled bottle. She then returned the bottle to the serving line where it continued to be used as a dressing for fortified diet plates.
In an interview on 8/4/23 at 1 p.m. in the kitchen, the DSS confirmed she had mixed fresh butter-sauce in with the older butter sauce in the bottle and the date on the bottle indicated when the bottle was initially filled on 7/25/23. The DSS also stated she should have put the butter sauce in a clean bottle and labeled it with a new date.
A review of the facility's policy and procedure titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practice, revised November 2022, indicated, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness .All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices .
A review of the 2022 U.S. Food and Drug Administration Food Code, indicated, .Containers in serving situations such as salad bars, [NAME], and cafeteria lines hold READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD .are intermittently combined with additional supplies of the same FOOD .the containers are cleaned at least every 24 hours .
3. During a concurrent observation and interview on 8/1/23 at 8:50 a.m., Licensed Nurse 1 (LN 1) was administering medications for a resident in room [ROOM NUMBER]. The LN 1 did not conduct hand hygiene before a medication administration and after exiting the resident's room. The LN 1 confirmed she did not wash hands after leaving the resident's room.
During an observation on 8/1/23 at 3:09 p.m., LN 4 entered room [ROOM NUMBER] to give medications to a resident and there was no hand hygiene observed.
During an observation on 8/1/23 at 3:30 p.m., LN 4 put on gloves to give an injectable medication to a resident. There was no hand hygiene before putting on gloves. LN 4 confirmed she did not use hand hygiene before putting on gloves.
During an observation on 8/1/23 at 3:50 p.m., LN 5 removed the gloves and put on a new pair of gloves before starting the blood sugar check for a resident. There was no hand hygiene observed after removing gloves and before putting on gloves.
During an interview on 8/1/23 at 4 p.m., LN 5 confirmed she should have use hand sanitizer before and after resident care. LN 5 stated there is an infection control risk if there is no hand hygiene.
During a concurrent observation and interview on 8/1/23 at 4:06 p.m., LN 6 put on gloves before starting a blood sugar check for a resident in room [ROOM NUMBER]. There was no hand hygiene before putting on gloves. LN 5 confirmed she should have done hand hygiene before and after removing gloves.
During an observation on 8/1/23 at 4:42 p.m., Certified Nursing Assistant 1 (CNA 1) was emptying the trash into the trash bins in the hallway. The CNA 1 removed gloves, then she walked into room [ROOM NUMBER] to assist a resident, afterward she exit room [ROOM NUMBER] and went into another room. There was no hand hygiene before and after exiting the resident's room.
During an interview on 8/4/23 at 11 a.m., the Director of Nursing (DON) confirmed nurses should wash their hands or use hand sanitizer before resident care and after exiting the residents' room.
During a review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2019, indicated, Use an alcohol-based hand rub containing at 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .Before and after direct contact with residents .Before preparing or handling medications .Before and after handling an invasive device (e.g. urinary catheters, IV access sites) .Before donning sterile gloves .After removing gloves .
4. In an observation and concurrent interview on 8/1/23 at 8:25 a.m., a juice dispensing machine was observed on the kitchen counter and two uncovered spike connectors for the beverage machine were left at the bottom of the shelf. The DSS confirmed the spike connectors were not in use and were left stored below the shelf. The DSS stated the spike connectors should be covered and kept in a sanitary condition. The DSS was asked for a policy and maintenance manual of the beverage machine but was unable to provide a manual or policy.
5. During the initial tour of the kitchen's dry storage room on 8/1/23 at 8:15 a.m. accompanied by the DSS, a space between the back of the refrigerator and freezer equipment and the kitchen wall measured approximately two feet wide and approximately 10 to 12 feet in length was observed. This space was littered with what appeared to be paper, plastic and brownish spots on the floor. In a concurrent interview with the DSS, she confirmed the space was littered with plastic and paper items on the floor. The DSS stated they were unable to clean behind the refrigerator and freezers because kitchen personnel were unable to reach it. The DSS stated she could not recall the last time the area was cleaned. The DSS stated she will ask maintenance to disconnect and move the equipment so they can sweep and clean the area.
6. During the initial tour of the kitchen on 8/1/23 at 8:35 a.m. the kitchen's bench can opener was inspected. The can opener's shank was removed and the base was exposed for viewing. The base of the shank was observed to have a film of black-colored sticky deposit. The base was wiped down with a clean white colored paper. The black-colored deposit adhered to the white paper. In a concurrent interview with the DSS she confirmed the black, sticky substance on the base of the can opener. She stated she did not know what it was but the can opener base should be cleaned before the shank of the can opener was replaced back into the base.
In a review of the facility document Cleaning Procedure #42 - Bench can opener dated 2017 indicated: .Shank and top of base are to be cleaned and sanitized after each use; the base plate will be removed and cleaned/sanitized monthly.
7. During a follow up tour of the kitchen on 8/3/23 at 10 a.m. accompanied by the Maintenance Supervisor (MS) and the Dietary Service Supervisor (DSS), the ice machine was opened for a closer look and observation. The MS stated he was not responsible for cleaning and maintaining the ice machine; the facility used an outside vendor who cleaned and maintained the ice machine every 6 months. The MS confirmed there was only one ice machine and it was located in the kitchen. The DSS confirmed her department only wiped down of the outside parts of the ice machine. The DSS also stated the last time the vendor came to clean the ice machine was approximately last December 2022. Upon disassembly of the outer coverings of the ice machine by the MS, there was a white plastic panel which faced the location where the water streamed out of the machine to create the ice. On the white plastic panel was multiple black and brown-colored substances. This substance was wiped down with a white tissue paper and it adhered to the white tissue paper. This was confirmed by the MS. The DSS was nowhere to be found to confirm the observation.
In a concurrent observation and interview on 8/3/23 at 10:35 a.m., the DSS was shown the ice machine. The DSS stated the ice machine was not sanitary and needed to be cleaned. The DSS stated the manufacturer's recommendation was to service and clean the ice machine every six months. The DSS provided a copy of the last service receipt by the outside vendor.
A review of the service receipt by the outside vendor indicated the last service was on 12/16/22.
In a follow-up interview with the DSS on 8/3/23 at 10:40 a.m., the DSS confirmed the only receipt she had for the ice machine maintenance was dated 12/6/22. She verified the ice machine should have been serviced in June 2023 but it was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation and record review the facility failed to maintain essential kitchen equipment in good working order and repair when:
1. The beverage dispensing machine was not kept in a sanitary ...
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Based on observation and record review the facility failed to maintain essential kitchen equipment in good working order and repair when:
1. The beverage dispensing machine was not kept in a sanitary condition;
2. The ice machine was not cleaned and sanitized; and,
3. The kitchen equipment cleaning schedule was not followed.
These failures had the potential for residents to become sick.
Findings:
1. In a tour of the kitchen on 8/1/23 at 8:25 a.m. there was a juice dispensing machine on the kitchen counter. The Dietary Service Supervisor (DSS) stated they use the machine to pour and serve juice for the residents. Upon further observation of the juice dispensing machine there were two spike connectors for the beverage machine which were not in use and were left at the bottom of the shelf. In a concurrent interview with the DSS she confirmed the connectors were not in use and were stored uncovered below the shelf. The DSS stated spiked connector ends should be covered. The DSS was asked for a policy and maintenance manual of the beverage machine, but was unable to provide one.
2. During a follow up tour of the kitchen on 8/3/23 at 10 a.m. accompanied by the Maintenance Supervisor (MS) and the DSS the ice machine was opened for a closer observation. In a concurrent interview with the MS, he stated he is not responsible for cleaning and maintaining the ice machine; an outside vendor cleans and maintains the ice machine every six months. The MS confirmed there was only one ice machine in the facility and it was located in the kitchen. In a concurrent interview with the DSS, she confirmed her department only wiped down the outside parts of the ice machine. The DSS stated the last time the outside vendor cleaned the ice machine was in December 2022. Upon disassembly of the outer coverings of the ice machine by the MS, there was a white plastic panel which faced the location where the water streamed out of the machine to create the ice. On the white plastic panel was multiple black and brown-colored substance. This substance was wiped down with a white tissue paper and adhered to the white tissue paper. This was confirmed by the MS. The DSS was nowhere to be found to confirm the observation.
In a concurrent observation and interview on 8/3/23 at 10:35 a.m., the DSS was shown the ice machine. The DSS stated the ice machine was not sanitary and needed to be cleaned. The DSS stated the manufacturer's recommendation was to service and clean the ice machine every six months. The DSS provided a copy of the last service receipt by the outside vendor.
A review of the service receipt by the outside vendor indicated the last service was on 12/16/22.
In a follow-up interview with the DSS on 8/3/23 at 10:40 a.m., the DSS confirmed the only receipt she had for the ice machine maintenance was dated 12/6/22. She verified the ice machine should have been serviced in June 2023 but it was not.
3. In an interview and concurrent record review on 8/3/23 at 1 p.m. the DSS provided a log titled Food and Nutrition: Cleaning log. The DSS stated the kitchen staff cleaned the equipment as scheduled on the log. A record review of the food and nutrition cleaning logs dated 7/17/23 to 8/6/23 indicated:
- The juice pump was not cleaned on 7/17/23, 7/18/23, 7/27/23, 7/28/23, 7/29/23, 7/30/23 as evidenced by the lack of kitchen staff initials to indicate who completed the task.
- The stove tops, steamer, freezer and fridge fronts, the oven front, and a sweep and mop of the cook's area was not cleaned on 7/30/23 as evidenced by the lack of kitchen staff initials to indicate who completed the task.
The DSS confirmed there were no initials logs for the dates listed and stated if it is not initialed, then the task was not done. The DSS stated she expected the kitchen staff to complete the tasks as assigned. The DSS stated she reviewed the log but did not conduct corrective action to keep the cleaning log accurate and ensure the equipment was cleaned as scheduled.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident bedrooms measured at least 80 square feet per residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in 11 shared rooms.
This failure had the potential to limit the personal belongings of each resident and compromise their ability to safely move freely in their rooms.
Findings:
During an initial tour observation on 8/1/23, starting at 8:42 a.m., the following rooms were observed to not meet the minimum space requirement for each resident:
Room
Occupancy Square Foot/Resident Required/Actual
2
2 Residents
66.6
160/142
3
2 Residents
71.5
160/143
4
2 Residents
72
160/144
8
3 Residents
67.7
240/203
41
3 Residents
75.6
240/227
43
3 Residents
74
240/223
44
2 Residents
72.5
160/145
45
3 Residents
74.6
240/224
46
2 Residents
75
160/150
47
3 Residents
76.6
240/230
48
2 Residents
72
160/144
During an initial tour interview on 8/1/23, at 9:20 a.m., in room [ROOM NUMBER], Resident 61 stated the room feels small for 3 people.
During a continuing observation on 8/1/23, at 10 a.m., all rooms had adequate space for resident's beds, wheelchairs, and bedside tables. Staff were able to move easily in and out of all rooms.
During an interview on 8/1/23, at 10:01 a.m., in room [ROOM NUMBER], Resident 176 stated she had no issues with the room size.
During an interview on 8/1/23, at 10:03 a.m., Licensed Nurse (LN) 1 stated she was able to move residents in and out of the rooms with no issues.
Based on the findings during Re-certification survey, the Department recommends the continuation of the room size waiver for rooms 2, 3, 4, 44, 46, and 48 housing 2 residents each room.
The Department recommends the continuation of the room size waiver for rooms 8, 41, 43, 45, and 47 housing 3 residents each room.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure wound care orders and preventative measures wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure wound care orders and preventative measures were consistently implemented for one of 3 sampled Residents (Resident 1) when:
1.A physician order for a Low Air Loss Mattress (LAL mattress, a special mattress used for both prevention and treatment of pressure wounds) was not evaluated for necessity, and
2. Resident 1's buttocks dressing was not in place as per the wound orders.
These failures had the risk potential for Resident 1's bilateral buttock wound to deteriorate.
Findings:
According to Resident 1's admission Record he was admitted to the facility on [DATE], with multiple diagnoses which included atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), diabetes, muscle weakness, difficulty walking, hypertension (high blood pressure), and heart failure.
1.A review of Resident 1's admission Skin Assessment, dated 3/16/23, indicated he had open areas in both buttocks and, under preventative measures, a LAL mattress was selected.
Review of Resident 1's Skin Assessment, dated 3/17/23, indicated he had excoriations (skin abrasions) to the right and left buttock and, under preventative measures, a LAL mattress was not marked.
Resident 1's physician order, dated 3/16/23, was reviewed and indicated, .low air loss mattress.
A review of Resident 1's Treatment Administration Record, dated 3/1/23-3/31/23 indicated, Cleanse excoriation to bilateral buttocks with NS [normal saline], pat dry, apply Hydrocolloid dressing QOD [EVERY OTHER DAY] and PRN [as needed] until healed.
During an interview with Licensed Nurse (LN 2) on 3/28/23, at 2:12 p.m., LN 2 stated she had assessed Resident 1's skin on 3/17/23 and noted he had excoriations to both buttocks. LN 2 stated she reviewed the treatment order from the hospital referral documents and the order was changed to a hydrocolloid dressing to be applied every other day and as needed if the dressing was dislodged or soiled. LN 2 stated the resident was at risk for skin breakdown due to moisture from being incontinent to bowel and bladder. LN 2 stated the resident did not meet the criteria for an LAL mattress because he did not have stage 3 (full thickness skin loss) or greater pressure ulcers (injury to skin from prolonged pressure). LN 2 stated if the resident met the criteria for an LAL mattress, his physician orders would include an LAL mattress.
An interview conducted with the Director of Nursing (DON) on 3/30/23, at 11:31 a.m., the DON stated she would have expected the licensed nurse or the wound nurse to call the physician regarding the order for a LAL mattress to determine if the order needed to be discontinued or implemented.
2. According to an Intake Report received by the Department on 3/23/23, Resident 1 had stated his, butt hurt, and was noted to have stage 2 pressure ulcers (damaged skin with an open sore, scrape or blister present) that were, uncovered [no dressing].
An interview conducted with LN 2 on 3/28/23, at 2:12 p.m. LN 2 stated she had done the wound care for Resident 1 and placed a dressing on his buttocks on 3/21/23, and if the dressing was soiled or dislodged, the nurse assigned should clean the wounds and place another dressing as per the orders. LN 2 verified a dressing had been placed on 3/22/23 at 2:17 p.m.
During an interview with a Certified Nursing Assistant (CNA 3) on 3/28/23, at 3:49 p.m., she stated when she provided incontinent care for Resident 1 on 3/22/23 early in the afternoon shift, she noted there was no dressing on his buttocks. CNA 3 stated there were two ladies in the room and the resident had a bowel movement when she changed his brief.
During an interview with LN 4 on 3/29/23, at 11:34 a.m., LN 4 stated she was assigned to Resident 1 on 3/22/23, during the morning shift. LN 4 stated she had gone to Resident 1's room because the family had complained incontinence care had not been provided to the resident. LN 4 stated she noted the resident had a bowel movement and the buttocks dressing was not present. LN 4 stated she enlisted the help of another LN, and they cleaned the sites and placed a dressing as per the orders. LN 4 stated she was not able to establish whether the dressing had been dislodged during the day shift or night shift.
During an interview with the DON on 3/30/23, at 11:31 a.m., the DON stated she expected the CNAs to notify the charge nurse or the wound nurse if a resident's wound dressing was noted dislodged, soiled or not in place during incontinent care so that a new one can be placed.
A review of the facility's policy and procedure titled Prevention of Pressure Ulcers/Injuries, dated 7/2017 indicated in part, The purpose of this procedure is to provide information regarding identification of pressure ulcer/ injury risk factors and interventions for specific risk factors . [under prevention of pressure ulcers indicated] Keep the skin clean and free of exposure to urine and fecal matter . Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion [the means by which blood provides nutrients and remove waste to maintain healthy tissues], body size, weight, and overall risk factors.
Jun 2019
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dignity and respect were maintained for two of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dignity and respect were maintained for two of 20 sampled residents (Resident 60 and Resident 44) when:
1.
Staff did not knock on the door before entering resident's room; and
2.
Staff stood over the resident while assisting him to eat.
These failures increased the potential to diminish residents' self-esteem and self-worth.
Findings:
1. According to the 'admission Record', the facility admitted Resident 60 in early 2015 with diagnoses which included Parkinson's disease (a disorder of the brain that causes stiffness and shaking) and osteoarthritis (bone joint disease).
A review of the latest Minimum Data Set (MDS, an assessment tool) dated 5/12/19, indicated Resident 60 scored 1 out of 15 on a Brief Interview for Mental Status (BIMS, an assessment for cognitive function), indicating severe memory deficit.
During an observation on 6/19/19 at 2:30 p.m., Resident 60 was sleeping in her bed. Certified Nurse Assistant (CNA) 1 entered Resident 60's room without knocking on the door and did not introduce herself when she entered the room.
During an interview on 6/20/19 at 1:30 p.m., CNA 1 stated that knocking on the door and introducing herself skipped her mind. CNA 1 further stated that she should have knocked on the door before entering and introduced herself to the resident.
The facility policy titled Quality of Life - Dignity revised August 2009, indicated Residents shall be treated with dignity and respect at all times .Staff will knock and request permission before entering residents' rooms.
During an interview on 6/20/19 at 2 p.m., the Administrator (ADM) stated that it was expected that all staff should knock on resident's door and introduce themselves before entering the resident's rooms. The ADM acknowledged that the CNA 1 should have knocked on the door and introduced herself before entering Resident 60's room.
2. According to the 'admission Record', the facility admitted Resident 44 in mid-2017 with diagnoses which included dementia (memory loss) and hearing loss.
A review of the latest MDS dated [DATE], indicated Resident 44 scored 99 on BIMS, indicating Resident 44 was unable to complete interview.
During an observation and concurrent interview on 6/19/19 at 2:30 p.m., Resident 44 was seated in a chair by the door. CNA 2 was observed standing over Resident 44 while helping the resident eat ice cream for snacks. CNA 2 stated that she should have been sitting at the resident's eye level while assisting Resident 44 to eat.
During an interview on 6/20/19 at 10:15 a.m., Licensed Nurse (LN) 1 stated that CNA 2 should have been sitting at the resident's eye level when she helped feed Resident 44.
The facility policy titled Quality of Life - Dignity revised August 2009, indicated Each resident shall be cared for in a manner that promises and enhances quality of life, dignity, respect and individuality.
During an interview on 6/20/19 at 10:35 a.m., the Director of Nursing (DON) stated that the staff should have been sitting at the resident's eye level while she helped Resident 44. DON acknowledged it was a dignity issue when CNA 1 was not seated at eye level when helping resident 44 to eat.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have a POLST (Physician Orders for Life-Sustaining Trea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have a POLST (Physician Orders for Life-Sustaining Treatment-a document that records resident's treatment wishes) record in one of 20 sampled resident's chart (Resident 76).
This failure had the potential for the resident to receive care that was contradictory to her health care treatment wishes.
Findings:
According to the 'Resident Face Sheet', Resident 76 was admitted early 2018 with diagnoses that included dementia and age related osteoporosis (A condition in which bones become weak and brittle.). The assessment dated [DATE] indicated she was severely mentally impaired and required extensive assistance for all activities of daily living.
During an observation of Resident 76's clinical chart and concurrent interview with Licensed Nurse (LN 3) on [DATE] at 11:06 a.m., LN 3 confirmed there was no documented evidence that the resident had a POLST filled out to indicate her code status (whether a patient wishes treatment to prolong their life).
During a review of the clinical record for Resident 76 the Advanced Healthcare Directive dated [DATE], indicated that, In the event that your heart and breathing stop, Resident's wishes were: I want CPR attempted (Cardiopulmonary Resuscitation).
During a review of the clinical record for Resident 76 the Physician Orders print dated [DATE], indicated that the Code Status was DNR (Do Not Resuscitate) in contradiction to the Advanced Directive.
During a review of the clinical record for Resident 76 the Resident Face Sheet indicated that There are no Advanced Directives Selected for this resident. (There was an Advanced Directive). The Face Sheet also indicated to See POLST form in chart for code status. (There was no POLST in the chart).
In an interview with the Director of Nurses (DON) on [DATE] at 11:12 a.m., she also confirmed there was no POLST in Resident 76's medical chart. The DON further stated that the resident names on the doors to their rooms are colored coded to indicate code status for the residents. She stated that if a resident's name is written in black they should be a full code and if the name is written in red they have a code status as DNR- do not resuscitate.
During an observation on [DATE] at 11:15 a.m., of Resident 76's door way, her name sign was black which would have indicated she was a Full Code.
During an interview with LN 3 on [DATE] at 11:06 a.m., she stated she did not know what the code status was for Resident 76.
The facility was unable to produce a policy on Advanced Directives/POLST.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure personal hygiene was maintained for one of 20 sampled residents (Resident 45) when her fingernails were dirty and untr...
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Based on observation, interview, and record review, the facility failed to ensure personal hygiene was maintained for one of 20 sampled residents (Resident 45) when her fingernails were dirty and untrimmed.
This failure had the potential to negatively impact Resident 45's psychosocial well-being as well as injuring resident's skin and promote infections.
Findings:
According to the 'admission Record', the facility admitted Resident 45 in late 2018 with diagnoses which included tremor (uncontrollable shaking) and age-related osteoporosis (bone disease).
A review of the most recent Minimum Data Set (MDS, an assessment tool), dated 4/21/19, indicated Resident 45 scored 11 out of 15 on a Brief Interview for Mental Status (BIMS, an assessment for memory that use scores from 1-15 with 15 designating no memory loss), indicating mild memory deficit. The MDS reflected she was totally dependent on others for assistance with ADLs (activities of daily living) and required 1-person assistance to provide personal hygiene.
A review of Resident 45's ADL Care Plan dated 10/18/18, indicated that Resident 45 required extensive assistance for setting up equipment for hygiene/grooming.
During an observation 6/18/19, at 4:35 p.m., Resident 45's was sitting in a chair, her fingernails were noted to be untrimmed about 1/4 centimeters in length from the fingertips, jagged, yellowish in color, dirty with black substance underneath the nail beds.
During an interview on 6/18/19, at 4:48 p.m., LN 2 stated that Resident 45's fingernails were dirty and untrimmed. LN 2 further stated that CNAs should have cleaned and trimmed Resident 45's fingernails.
The facility policy and procedure titled Care of Fingernails/Toenails revised October 2010, indicated The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Proper nail care can aid in the prevention of skin problems .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.
During an interview on 6/18/19, at 4:41 p.m., the DON stated that it is the CNAs job to check, clean and trim the residents' fingernails. The DON acknowledged that Resident 45's nails should have been cleaned and trimmed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure preventative interventions for pressure ulcers were implemented in a timely manner for 1 of 20 sampled residents (Resid...
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Based on observation, interview and record review, the facility failed to ensure preventative interventions for pressure ulcers were implemented in a timely manner for 1 of 20 sampled residents (Resident 3) when:
1. A special mattress was not provided in a timely manner, and,
2. Wound dressing was not dated and the resident was not repositioned after wound care.
These failures resulted in Resident 3 acquiring a potentially avoidable pressure ulcer to the coccyx (tail bone).
Findings:
According to the 'Resident Face Sheet' the facility admitted Resident 3 early this year with multiple diagnoses including status post right hip fracture surgical repair, anemia and lung disease. The admission Assessment indicated Resident 3 required extensive assistance to move in bed, was always incontinent with bowel and bladder and had moderate cognitive impairment. The assessment indicated she had no pressure ulcers but was at risk for pressure ulcer development.
1. During the Initial Pool on 6/18/19 at 10 a.m., Resident 3 was observed sitting up in wheelchair in her room and reported she had a pressure ulcer to the buttocks.
Resident 3's clinical record was reviewed as follows:
A 'Pressure Ulcer Risk Assessment' dated 3/2/19 indicated she scored 11 (a total score of 8 or above represented HIGH RISK), . The resident should be considered HIGH RISK for skin breakdown [ .and] prevention protocol should be initiated.
A review of Resident 3's 'Weight Record' indicated the admission weight on 2/26/19 was 151.4 pounds and 151.4 pounds on 3/3/19. On 3/10/19, the weight was documented as 132.5 pounds and a weight loss of 18.9 pounds was documented. This represented a significant weight loss of 18.9 pounds in 7 days and a 14.2% weight loss.
A review of Resident 3's 'Tracking Form' for 3/2019 indicated her meal intake for the month was poor (25-49% meal eaten) or refused (0-24% meal eaten).
A 'Short Term Skin Care Plan' dated 3/21/19 indicated Resident 3 developed a stage 2 coccyx pressure ulcer that was documented on the pressure ulcer form dated 3/21/19 as measuring 1.6 by 0.8 by 0.2 centimeters (unit of measurements- length, width and depth respectively) and noted to contain slough (dead tissue).
The 'Skin Risk Breakdown' care plan dated 2/26/19 indicated the resident's goal was, 'No skin breakdown .' The care plan indicated an air mattress overlay was not provided until 3/13/19, fifteen days later.
A review of the facility's undated 'Wound and Skin Management' policy indicated in part, A pressure ulcer is defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue. Pressure ulcers occur over bony prominence's and are graded or staged to classify the degree of tissue damage observed. Friction and shear are important factors to the development of pressure ulcers . Avoidable means that the resident developed a pressure ulcer and the facility did not . implement interventions that are consistent with resident needs, resident goals .
A review of the facility's undated 'Wound And Skin Management' policy indicated, It is the policy of this facility that any resident who enters the facility without pressure sores will have appropriate preventative measures taken to insure that the resident does not develop pressure ulcers . The policy also contained a list of preventative measures including pressure reducing devices in bed and wheelchair for those identified to be at risk for skin breakdown.
During an interview and concurrent clinical record review of Resident 3's record with the Director of Nursing (DON) on 6/21/19 at 11:53 a.m., she stated the air mattress to the bed was initiated a week prior to the identification of the coccyx pressure ulcer, but should have been implemented on admission as she was assessed as high risk for skin breakdown.
2. On 6/21/19 at 11:35 a.m., Resident 3 had just been transferred to bed from the wheelchair after participating in activities and was lying on her back. Licensed Nurse 2 (LN 2) was observed as she assisted the resident to a side lying position and cleaned and changed the dressing to the coccyx pressure ulcer. LN 2 then assisted the resident back to the same back lying position after the procedure. LN 2 did not date the dressing she applied and she did not reposition Resident 3 to another position.
During a concurrent interview with LN 2 on 6/21/19 at 11:35 a.m., she stated dressings should not be dated because the ink might get into the wound. LN 2 further stated she should have placed Resident 3 in a different position.
A review of Resident 3's at risk for 'Skin Breakdown Care Plan' dated 2/26/19 indicated one of the interventions was to turn and/or reposition the resident every 2 hours.
A review of the facility's 'Wound Care' policy dated 10/2010 indicated in part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . [NAME] tape with initials, time and date and apply to the dressing . [document] The position in which the resident was placed.
During an interview with the DON on 6/21/19 at 11:53 a.m., she stated LN 2 should have dated Resident 3's new dressing and placed her in another position in bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review for one of 20 sampled residents (Resident 76) the facility did not follow Rest...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review for one of 20 sampled residents (Resident 76) the facility did not follow Restorative Nurse Assistant (RNA) goals for prevention/decline in range of motion and contractures (a deformity that limits range of motion) when Resident 76's hand roll was not applied.
This had the potential to cause further decline of Resident 76's range of motion and permanent contractures of her hands and fingers.
Findings:
According to the 'Resident Face Sheet', Resident 76 was admitted early 2018 with diagnoses that included dementia and age related osteoporosis (A condition in which bones become weak and brittle). The Minimum Data assessment dated [DATE] indicated, she was severely mentally impaired and required extensive assistance for all activities of daily living.
During an observation and concurrent interview with Certified Nursing Assistant (CNA 4) on 6/19/19 at 8:24 a.m., Resident 76 was sitting up in bed. Her right hand was curled up tightly. There was no visible hand roll. When asked if the resident should have a hand roll, CNA 4 stated that Resident 76 should have them on. CNA 4 confirmed there was no hand roll. CNA 4 continued to look in the bed and around the bed and was not able to locate the hand roll which indicated the resident did not take them off herself.
During an observation and concurrent interview with CNA 3 on 6/20/19 at 1:40 p.m., Resident 76 was in her room sitting on her wheelchair playing with her doll. There was no hand roll seen. When asked, CNA 3 stated that the resident had a hand roll on this morning and stated it was velcroed on. Another CNA walked by and stated that she had used a wash cloth this morning to use as a hand roll and not the velcro one. Both CNAs confirmed that Resident 76 should have a hand roll in place at all times.
Review of the clinical record for Resident 76, the Restorative Nursing Care Plan dated 3/5/18 indicated that Resident 76 was at risk for loss of mobility due to Osteoporosis. Goals were listed as: will be able to tolerate right hand roll. Approach/Plan list included: passive range of motion and hand roll. Re- evaluation dates were 6/19 and 9/19.
Review of the clinical record for Resident 76, the Recommendations for Restorative Nursing dated 5/22/19 indicated under Special Instructions, Keep hand roll in right hand all times
Review of the clinical record for Resident 76, the Weekly Summary dated 6/15/19, indicated resident works with RNA on passive range of motion and hand roll.
The facility policy and procedure titled Restorative Nursing Services dated July 2017 indicated, Restorative goals and objectives are individualized and resident-centered, and are outlined in the individual resident's plan of care .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards for two residents (Resident 30 and Resident 56) of 20 s...
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Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards for two residents (Resident 30 and Resident 56) of 20 sampled residents when:
1. Resident 30 fell forward out of her wheelchair when she tried to propel herself over the raised threshold of her room; and,
2. Resident 56 scraped her hand on a door jam when Certified Nursing Assistant (CNA) struggled to pull her in a shower chair over a raised threshold.
This failure caused a fall and injury for two residents and had the potential to cause falls and injury for all residents of the facility.
Findings:
1. According to the Resident Face Sheet, Resident 30 was admitted in March of 2019 with diagnoses including Parkinson's disease (a disorder of the brain that causes stiffness and shaking).
During interviews with Residents 2, 37, and 54 on 6/19/19 at 10:15 a.m., during the Resident Council Meeting, Resident 54 stated that she had mentioned to the Maintenance Supervisor (MS) that the thresholds [at the entrance to resident rooms] are too high. She stated that it was a safety concern. Resident 2 and 37 stated that going over the thresholds jar you and you can get stuck.
During multiple observations on 6/19/19 starting at 10:30 a.m., all resident rooms were noted to have metal door thresholds that were raised between the resident rooms and the hallways. The shower rooms also had the raised metal thresholds.
During an interview with Resident 30 on 6/19/19 at 11:08 a.m., she stated that on Sunday [6/16/18] she was in her wheelchair and wanted to leave her room. Resident 30 added that she was having difficulty going over the threshold in her room and fell forward out of her chair and hit her face.
During and interview with CNA 6 on 6/19/19 at 11:10 a.m., CNA 6 stated that it is hard to push the wheelchairs over the thresholds and that the residents feel it when you go over the bump.
During a record review of Resident 30's clinical record, the document titled IDT Progress Notes (Interdisciplinary team notes) dated 6/17/19, indicated that, [Resident 30] had a fall on 6/16/19 at 8:15 p.m., from her wheelchair while attempting to cross the threshold from her room to the hallway.
During a record review of Resident 30's clinical record, the document titled Post Fall Evaluation dated 6/17/19, indicated under the Description of Fall: Called to hallway by dietary staff, CNA by patient [Resident 30] at this time. Patient noted to be laying in hallway on her left side. Patient's wheelchair in the doorway. CNA stated that she saw the patient trying to come out of room, front wheels hit the threshold and patient fell out of wheelchair. States she witnessed patient hit her head .
2. According to the Resident Face Sheet, Resident 56 was admitted in October of 2018 with diagnoses including dementia.
During an observation and interview with Resident 56 on 6/19/19 at 11:35 a.m., she stated she hit her hand on the door jam of a doorway when a CNA was pulling her out of the shower room in a shower chair. Resident 56 stated, The CNA couldn't pull me out, my hands were on the arm rest and when she struggled to get me over the threshold my hand scraped the door jam. Observation of the resident's left hand showed a 4 x 4 gauze over the wound. The resident stated her fingers hurt and are hard to move but she could move them. I took an aspirin, this just happened on Monday, day before yesterday [6/17/19].
During an interview on 6/19/19 at 11:50 a.m., CNA 4 stated that the shower chairs we use are hard to pull over the thresholds of the resident rooms and the shower room.
During a record review of Resident 56's clinical record, the document titled Nurses Notes dated 6/17/19 indicated, Resident noted to have 2 skin tears to top of left hand, CNA stated it happened while they were leaving shower room resident bumped hand on the door .
During an interview with CNA 2 on 6/19/19 at 1:32 p.m., CNA 2 stated she was pulling Resident 56 out of the shower and had to use a big shower chair and that it was hard to get the chair over the threshold. CNA 2 further stated that was how the resident's hand got scratched. The thresholds are too high and very hard to get the shower chairs over them.
During an observation and concurrent interview on 6/20/19 at 9:40 a.m., two CNAs were observed assisting a resident into the shower room. The resident was sitting on a shower chair and when they got to the threshold of the shower room the chair got stuck. The two CNA's pulled the chair back into the hall then quickly pushed and pulled it and the resident over the threshold. CNA 2 stated that , This is how Resident 56 got her hand hurt. You can see how hard it is for us to get in that [shower] room, the door is small and the shower chair is big and then the threshold is hard to get over. CNA 3 stated that it was difficult to maneuver into the shower room with the high threshold and narrow door.
The facility policy and procedure titled Accidents and Incidents-Investigating and Reporting dated July 2017 indicated, .Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected 1 resident
Based on interview, personnel file and policy review, the facility failed to ensure a qualified Dietary Manager was hired in the absence of a full-time Registered Dietician (RD) for a census of 84.
Th...
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Based on interview, personnel file and policy review, the facility failed to ensure a qualified Dietary Manager was hired in the absence of a full-time Registered Dietician (RD) for a census of 84.
This failure had the potential for the resident's nutritional needs not to be met.
Findings:
During the Initial Kitchen Tour accompanied by a staff who introduced herself as the Assistant Dietary Supervisor (ADS) on 6/18/19 at 8:50 a.m., she stated that she was appointed to the position of a Dietary Manager recently on condition she was going to complete the education requirements for the position, which she had not. The ADS stated she had notified the outgoing facility Administrator that she did not wish to go back to school. The ADS stated the facility's dietician only worked twice per week.
An interview conducted with the Consultant Dietary Manager (CDM) on 6/19/19 at 10:05 a.m., she stated she had come in that day to help the facility. The CDM stated she worked in another facility but she was aware the facility did not have a qualified dietary manager and the dietician only worked 2 days per week.
A review of the personnel files provided by the facility included the ADS file that had no documented evidence she met the qualification of a dietary manager in the absence of a full-time dietician as required by the regulations. The facility had provided 2 other personnel files for staff who had been hired last year but had quit.
A review of the RD printed time for the period between 1/2019 and 5/2019 did not meet the minimum full-time requirement for the dietician (32 hours/week).
During an interview conducted with the Administrator on 6/20/19 at 11:20 a.m., he stated the facility had no qualified dietary manager and the dietician only worked 2 days per week. The Administrator further stated the facility's plan was to increase the hours for the RD until they have a dietary manager in place.
A review of the facility's 'Personnel Management' policy dated 1/1/2017 indicated the 'Director of Food & Nutrition Services' education requirements was, . meets the requirements for [State name] Health and Safety code 1265.4; . meets the requirements for [government agency's name] regulation .[has] Food Protection Manager Certificate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected 1 resident
Based on observation, interview and the Facility's Assessment document review, the facility failed to ensure the assessment included all elements as stipulated by the regulation.
These failures had t...
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Based on observation, interview and the Facility's Assessment document review, the facility failed to ensure the assessment included all elements as stipulated by the regulation.
These failures had the potential for the facility not to include management of all the risks in their annual plan.
Findings:
A review of the 'Facility Assessment' document dated 4/1/19 reflected no documented evidence that an assessment of the Health Information and Emergency Management were included.
During an interview and concurrent Facility Assessment review with a Nurse Consultant (NC) on 6/20/19 at 10 a.m., she stated the assessment was inaccurate and the facility was working on it.
An interview conducted on 6/20/19 at 11:20 a.m. with the Administrator, he stated the assessment lacked some of the essential components and handed in another copy. The Administrator was asked for the assessment policy guideline and he stated they were in the middle of acquiring the facility and a policy would be developed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, interview and document review, the facility failed to ensure the kitchen equipment was repaired in a timely manner for a census of 84.
This failure had the potential to negativel...
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Based on observation, interview and document review, the facility failed to ensure the kitchen equipment was repaired in a timely manner for a census of 84.
This failure had the potential to negatively impact the resident's food and services.
Findings:
During the Initial Kitchen Tour on 6/18/19 starting at 8:50 a.m., accompanied by the Assistant Dietary Supervisor (ADS), external air conditioning equipment was observed coming through the window with a long tubing directed towards the stove area. The Kitchen staff were observed as they navigated their way from one side of the kitchen to the other as the tubing was blocking their way.
A concurrent interview conducted with the ADS on 6/18/19 at 8:50 a.m., she stated, the ventilation system located near the stoves was broken two weeks ago and the facility needed to replace the entire system. The ADS stated the external equipment was put in place to cool down the kitchen environment which had become unbearable. The ADS stated she was not sure when the ventilation system would be fixed.
During a follow up kitchen observation on 6/19/19 starting from 9 a.m., the following equipment was observed broken or in need of repair:
a. The steam hold handle was broken and the rubber seal was not closing properly;
b. One of the 3 stove's oven door was broken and the oven was not operational;
c. 5 cabinets located near the microwave and next to a food preparation area were noted with peeling of the wall paper;
d. The door to a cabinet located to the left of the kitchen door was missing exposing water pitchers and,
e. The electrical mixer was reported broken and the staff were observed struggling to use a manual mixer as they prepared the desert for the lunch meal.
During a concurrent interview with the Kitchen Staff (KS) on 6/19/19 starting from 9 a.m., they stated the equipment was reported broken to the administration and they have been waiting for them to be repaired. The KS stated they worked with what was available and sometimes it took longer to prepare food.
During an interview with the ADS on 6/18/19 at 10:30 a.m., she validated the above equipment was broken and stated, I have been asking the prior owner to fix them.
A review of the facility's 'Maintenance Service' policy dated 12/2009 indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment.
An interview conducted with the Administrator on 6/20/19 at 11:20 a.m., he stated he was aware of the multiple broken equipment in the kitchen and the facility was in the process of replacing or repairing them but they should have been replaced and/or repaired in a timely manner.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation and interview, the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in 11 shared rooms.
This failure had the potential to limit the perso...
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Based on observation and interview, the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in 11 shared rooms.
This failure had the potential to limit the personal belongings of each resident and compromise their ability to safely move freely in their rooms.
Findings:
During an observation on 6/18/19, at 9 a.m., the following rooms were observed to not meet the minimum space requirement for each resident:
Room
Occupancy
Sq. Ft/ Res
Req/Actual
2
2 Residents
66.6
160/142
3
2 Residents
71.5
160/143
4
2 Residents
72
160/144
8
3 Residents
67.7
240/203
41
3 Residents
75.6
240/227
43
3 Residents
74
240/223
44
2 Residents
72.5
160/145
45
3 Residents
74.6
240/224
46
2 Residents
75
160/150
47
3 Residents
76.6
240/230
48
2 Residents
72
160/144
During a continuing observation on 6/18/19, at 9:20 a.m., all rooms had adequate space for resident's beds, wheelchairs and bedside tables. Staff were able to move easily in and out of all rooms.
During an interview on 6/18/19, at 9:40 a.m., LN 2 stated there appeared to be adequate space for the three beds and three wheel chairs. LN 2 stated that the room was plenty big and she and the staff had no difficulties in moving around and providing care for the three residents in a room.
During an interview on 6/18/19 at 10 a.m., Resident 18 stated that she doesn't have issues moving in the room and getting out with her wheelchair.
During an interview on 6/19/19 at 9:30 a.m., LN 1 stated that she doesn't have any issues about moving the residents in the rooms in station 2.
During an interview on 6/19/19 at 9:45 a.m., CNA 2 stated that she had no issues with moving around the room to provide care for the residents.
During an observation and concurrent interview on 6/20/19 at 10 a.m., Resident 229 stated she had plenty of space for her therapy.
During the Resident Council meeting interviews on 6/19/19, residents did not express dissatisfaction with the size of their rooms. During the survey starting 6/18/19 through 6/21/19, residents in the locked unit were observed as they went in and out of their rooms. Caregivers were also observed as they provided care for residents in their rooms.
In a group interview conducted with a Licensed Nurse and two Certified Nursing Assistants on 6/19/19 at 11:28 a.m., they stated they had no issues providing care to the residents in their rooms.
Based on the findings during Re-certification survey, the Department recommends the continuation of the room size waiver for rooms 2, 3, 4, 44, 46 and 48 housing 2 residents each.
The Department recommends continuation of the room size waiver for rooms 8, 41, 43, 45, and 47 housing 3 residents each.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
- • 45% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Lodi Creek Post Acute's CMS Rating?
CMS assigns LODI CREEK POST ACUTE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Lodi Creek Post Acute Staffed?
CMS rates LODI CREEK POST ACUTE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 45%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 80%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Lodi Creek Post Acute?
State health inspectors documented 43 deficiencies at LODI CREEK POST ACUTE during 2019 to 2025. These included: 41 with potential for harm and 2 minor or isolated issues.
Who Owns and Operates Lodi Creek Post Acute?
LODI CREEK POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LINKS HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 86 certified beds and approximately 81 residents (about 94% occupancy), it is a smaller facility located in LODI, California.
How Does Lodi Creek Post Acute Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, LODI CREEK POST ACUTE's overall rating (4 stars) is above the state average of 3.2, staff turnover (45%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Lodi Creek Post Acute?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Lodi Creek Post Acute Safe?
Based on CMS inspection data, LODI CREEK POST ACUTE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Lodi Creek Post Acute Stick Around?
LODI CREEK POST ACUTE has a staff turnover rate of 45%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Lodi Creek Post Acute Ever Fined?
LODI CREEK POST ACUTE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Lodi Creek Post Acute on Any Federal Watch List?
LODI CREEK POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.